CHPSO collects this information to help us understand how and why
items are left behind. Learning from both near misses and actual
events will help us better protect our patients. The form is
privileged under the Patient Safety and Quality Improvement Act
as hospitals are collecting this information to send to the
California Hospital Patient Safety Organization (CHPSO).
An item is left in the patient that is not supposed to be left
there as part of the procedure.
For example, this form would be used for a staple that was
dropped into the wound but not for a staple that is properly
placed. Another example would be a fragment intentionally left
behind because the risk of removal exceeds the risk of retention.
An item almost is left in the patient.
For example, the count is incorrect and steps are taken to find
the item, which is then found in the patient and removed prior to
leaving the OR.
A fragment is generated and retrieved.
For example, a drill bit breaks in the patient and the pieces are
found and removed.
You identify a hazard that could result in a retained surgical
For example, a new model of retractor has a removable section
that could be left behind, but you believe people are not aware
of it and that section isn’t being tracked.
Harm Score Definition
None – no symptoms detected and no treatment is required.
Mild – symptoms are mild, loss of function or harm is minimal
or intermediate but short term, and no or minimal intervention
(e.g., extra observation, investigation, review or minor
treatment) is required.
Moderate – intervention is required (e.g., additional
operative procedure; additional therapeutic treatment), or
increased length of stay occurs, or it caused permanent or long
term harm or loss of function.
Severe – life-saving intervention or major
surgical/medical intervention is required, or life expectancy is
shortened or there is major permanent or long term harm or loss
Death – on balance of probabilities, death was caused or
brought forward in the short term by the incident.
How to Participate
Hospitals intending to participate need to notify CHPSO by email
(firstname.lastname@example.org), follow the above instructions for filling out
the form for retained surgical items and near misses, and send
the information to CHPSO. Please email email@example.com if the
hospital decides to stop participation.