Incorrect Count Intra-Operative Radiographic Protocol

From the 2021 HVPAA National Conference

Abigail Cogman (University of Utah), Robert Glasgow, Catherine Hiatt, Alex Nieves, Yoshimi Anzai


A retained surgical foreign body (FB) is considered a “never event” by the Joint Commission and Department of HHS. In the event of an incorrect surgical count, an intra-operative radiograph (IOR) is performed. Inadequate communication between surgery and radiology regarding the nature of the missing item could lead to misdiagnosis/misinterpretation of a retained FB on the IOR. This project aims to increase patient safety by improving communication, thus reducing the chance of this never event.


A multi-disciplinary team of radiologists, surgeons, OR nursing team, and radiology technologists addressed the problem related to incorrect count IOR. One challenge was that radiologists did not know what a missing object looked like. A decision was made to take a radiograph of the missing object when the count was off. The policy was approved by the peri-operative executive committee.

To measure the new policy’s impact on radiologists’ confidence, the two sets of the survey were administered to radiologists (N=60), first without and later with a radiograph of a missing object. Radiologists were asked if the FB is present on IOR and their confidence level on a scale of 1-5, 5 being the most confident. The total survey completion rate was timed.


There were similar rates of the accuracy of FB detection. However, the survey results illustrated that the number of radiologists rating their confidence at 4 or 5 increased from 42% to 85% with the addition of the missing object’s radiograph. The time spent completing the survey was also decreased by an average of 25% with radiographic examples.


While we could not measure the incidence of retained FB as it is a rare event, the survey results showed an increase in radiologists’ confidence in diagnosing or excluding FB materials. The new policy should ultimately reduce misinterpretation of a retained FB and improve patient safety. The multi-disciplinary team approach to get buy-in from the OR team was critical for the policy implementation.

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