A Hearst Newspapers investigation, published on April 16, 2025, revealed that surgeons across the United States have inadvertently left surgical materials – such as sponges, wires, needles, drill bits, instruments, and broken tool fragments – inside patients’ bodies over the past decade. The full article is available on Hearst Newspapers’ platforms, such as the San Francisco Chronicle or Houston Chronicle
These incidents, known as retained surgical items (RSIs) or “never events,” are rare but can have severe consequences, including infections, organ damage, additional surgeries, and, in extreme cases, death. The investigation, conducted by reporters Emilie Munson and Leila Merrill, highlights the persistence of these medical errors despite protocols designed to prevent them, such as mandatory counting of surgical items and the use of radiopaque sponges visible on X-rays.
While exact numbers vary due to underreporting, studies cited in related sources estimate RSIs occur in approximately 1 in every 5,500 surgical procedures, with around 1,500 cases annually in the U.S. The Hearst investigation emphasizes that these incidents often require additional surgeries, extend hospital stays, and cause significant patient harm, such as infections, abscesses, or organ damage. For example, retained sponges, which account for 48% to 69% of RSIs, can lead to “gossypiboma,” where the body forms a mass around the foreign object, causing pain or complications like fistulas or bowel obstructions.
The investigation notes a range of items left behind, including:
– – Surgical sponges and gauze (most common, often used in large quantities during procedures).
– – Needles, wires, and drill bits.
– – Surgical instruments like clamps or retractors.
– – Broken fragments of tools, such as catheter tips or parts of wire cutters.These items are typically left in the abdomen, pelvis, or chest, but cases have been reported in vaginas, spinal canals, and even brains
The investigation points to human error as a primary cause, often due to:
– – Inaccurate manual counting of surgical items, which can be disrupted by complex procedures, shift changes, or distractions.
– – Poor communication among surgical teams.
– – Complacency or overconfidence in counts reported as correct, even when items are missing.
– – Inadequate documentation or failure to follow protocols like the World Health Organization’s surgical safety checklist.
The investigation references specific cases to illustrate the human toll:
– – A 2021 case where a woman suffered for 18 months after a plastic wound retractor (the size of a dinner plate) was left inside her abdomen following a C-section. An abdominal CT scan eventually
– – A 2018 case in Japan where a woman experienced abdominal bloating for six years due to two gauze sponges left during a C-section, which had adhered to her connective tissue and colon
– – A California man who suffered infections and septic shock from two retained surgical clamps, leading to a stroke.
The investigation underscores systemic challenges, including:
– – Underreporting of RSIs due to inconsistent definitions, varying reporting requirements, and fear of litigation.
– – Limitations of manual counting processes, which are prone to error in high-stress, complex surgeries, especially those involving obese patients or trauma cases requiring numerous instruments
– – Resistance to adopting new technologies, such as RFID-tagged sponges or barcode systems, due to cost or integration challenges, despite their potential to reduce errors.
– – RSIs lead to significant costs for hospitals, with a single case potentially costing up to $600,000 due to corrective surgeries and legal fees. Malpractice claims are common, with a 2003 study noting an average of $52,000 in compensation and legal expenses per case.
Hospitals employ several strategies to prevent RSIs, including:
– – Surgical teams count sponges, instruments, and other items before and after procedures. However, studies show that counts are often recorded as correct even when items are left behind.
– – Sponges and some instruments are embedded with X-ray-detectable materials to aid identification if left inside a patient.
– – The WHO surgical safety checklist and National Safety Standards for Invasive Procedures aim to standardize safety checks, but compliance varies.
– – Systems like ORLocate’s Surgical Counting and Detection System use RFID or barcode technology to track items more accurately, but adoption is not widespread.
Despite these measures, the investigation notes that errors persist due to the complexity of surgical environments, staff fatigue, and organizational pressures, such as high workloads or frequent staff changes during procedures.
The Hearst investigation aligns with prior studies and reports highlighting RSIs as a persistent patient safety issue. For instance, a 2008 study at the Mayo Clinic found RSIs in 1 in 5,500 surgeries, with most counts incorrectly reported as accurate. A 2017 article from the National Center for Biotechnology Information (NCBI) notes that RSIs can be life-threatening, often requiring further operations. The investigation also reflects Hearst Newspapers’ history of award-winning investigative journalism, as seen in their Polk Awards for reporting by the San Antonio Express-News and San Francisco Chronicle.
Discover Magazine on RSIs discusses real-world cases, such as the 2021 C-section retractor case and the 2018 Japanese gauze case, with broader implications. Washington Post on Never Events Reports 4,857 objects left in patients over two decades, with insights into malpractice claims and systemic issues. Times Union on New York Cases details specific RSI incidents, including a surgical sponge missed during a hysterectomy due to incorrect counting. PSNet on RSI Epidemiology offers data from California’s reporting system (2007–2011), noting 58% of RSI cases involved sponges or towels. Minnesota Department of Health reports 270 retained objects since 2003, emphasizing sponges and clamps as common items.