You’ve heard of UFOs but have you heard of RFOs? 194 Pennsylvanians could tell you about their RFO encounter last year – that’s how many cases of “retained foreign objects” were reported to that state’s Patient Safety Authority in 2008. The Authority has issued an analysis of methods for preventing these surgical errors that “may cause serious patient harm and often requires further medical treatment.”

To make matters worse, the cost of an RTO after surgery is $62,631 per hospital stay, according to the Centers for Medicare and Medicaid. Talk about driving up health care costs!

The typical line of defense is simply counting; accounting for the “sponges, sharps, and instruments” that were used during surgery in an attempt to ensure that none are left in the patient’s prior to closing up the body. Seems simple enough, but even though there is a “highly regulated process” for how to count, the Pennsylvania Patient Safety Authority received 2228 reports involving an incorrect sponge, sharp, or instrument count! Not all of those reports resulted in leaving something behind in patients’ bodies, but these incorrect counts demonstrate that a simple 1-2-3 does not always protect patients. So, what else can be done “Beyond the Count?”

The Patient Safety Authority advisory describes the other RFO prevention strategies–“radiographic screening, multidisciplinary approaches, and the use of assistive technology.” But technological methods will be costly, and they aren’t foolproof. And the multidisciplinary approach (reminding hospital staff how to count correctly along with developing standardized counting processes) could, ironically, create new steps to learn and mess up!

But they could help. So could another lesson with The Count on Sesame Street.