A patient underwent a vaginal hysterectomy, right ovarian cystectomy and an anterior and posterior vaginal repair. After the incision was closed, an x-ray was performed, which revealed that the sponge was in the posterior cul-de-sac. The vaginal cuff was reopened and the sponge was retrieved. Should code 998.4, Foreign body accidentally left during a procedure be reported?
Yes, report code 998.4, Foreign body accidentally left during a procedure. This advice is supported by National Quality Forum (NQF) directives which state that unintended retention of a foreign object in a patient after surgery or other procedure should be reported. The occurrence of unintended retention of objects at any point after the surgery ends should be captured regardless of setting or whether the object is removed.
Refer to the NQF website for additional information about "Serious Reportable Events in Healthcare":