Gossypiboma: Tales of lost sponges and lessons learned

Lisa K. McIntyre, Gregory Jurkovich, Martin L.D. Gunn, Ronald V. Maier

Research output: Contribution to journalArticlepeer-review

20 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)770-775
Number of pages6
JournalArchives of Surgery
Issue number8
StatePublished - Aug 1 2010
Externally publishedYes

ASJC Scopus subject areas

  • Surgery


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