Objective: To review the details surrounding cases of patients found to have retained laparotomy sponges after surgical procedures and share policy changes that have led to process improvements at one academic medical center. Design: Retrospective medical record review as part of a quality improvement process. Setting: Single academic medical center. Patients: Patients identified through the quality improvement process as having had retained foreign bodies after surgery. Conclusions: Sentinel events such as retained foreign bodies after surgery require intensive review to identify systems problems. This can lead to protocol changes to improve the process. After a series of incidents, protocol changes at our institution have led to no further incidents of retained foreign bodies.
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