Retained Surgical Sponges: Systematic Root Cause Analysis of 652 Reported Cases Using Data Analytics

Abstract

Annually, more than three million people die globally due to unsafe care, with one in ten patients being harmed while receiving care. According to a study by Johns Hopkins, an average of 251,454 Americans die every year from medical errors, ranking it the third leading cause of death after heart disease and cancer. Among different medical errors, retained foreign objects are one of the most common sentinel events. This study investigates 652 instances of retained surgical sponges reported to The Joint Commission from 2010 to the second quarter of 2020, using data analytics methods. Leadership, Communication, and Human Factors have been identified as the top three root causes of those incidents. Our recommendations focus on cultivating safety culture, enhancing leadership, refining communication, and establishing robust policies. Hospitals must prioritize patient safety, allocate budgets for comprehensive training, and implement clear communication guidelines. Standardized operating procedures and staff compliance are also paramount for error prevention.