It appears in as many as 1 in every 10,000 operations in the U.S. involving an open cavity, something inadvertently gets left behind after the patient had been closed up.
This is more common in emergency operations and accounts for a total of 1,500 operations each year.
As a rule 60% of the objects mislaid are sponges which can remain undetected for many years until something such as a serious infection develops which can be fatal.
No matter how rigorous medical staff are at accounting for equipment used, bits still go missing.
Now a new type of tagged surgical sponge has been invented which should go a long way to rectify the potentially lethal problem.
The device uses radio-frequency identification (RFID) and when medical staff wave a wand over the patient, the wand detects any sponges that are left inside.
When Dr. Alex Macario and a team at Stanford University, California, USA, conducted a small study using the device it proved to be effective for 100% of the time.
For the study at Stanford University Medical Center, tagged and un-tagged sponges were 'hidden' inside 8 patients who underwent abdominal or pelvic surgery by one surgeon, who then asked another surgeon to find them.
According to the researchers the battery-operated wand, a type of detector easily found the tagged sponges but not the others.
In less than 3 seconds the device detected all sponges correctly, and there were no mistakes.
RFID devices are commonly used in stores and for tagging pets and recently, some drug companies have been considering the technology for use in the fight to eliminate drug counterfeiting.
Using this technology for surgical sponges was the idea of a nurse who has patented it.