Sentinel Event Alert 51: Preventing unintended retained foreign objects

The unintended retention of foreign objects (URFOs) – also called retained surgical items (RSIs) – after invasive procedures can cause death, and surviving patients may sustain both physical and emotional harm, depending on the type of object retained and the length of time it is retained. There may be an extended time frame between occurrence and detection of an URFO. Retained foreign objects are most commonly detected immediately post-procedure; by X-ray; during routine follow-up visits; or from the patient’s report of pain or discomfort.