Although the literature describing cases of retained foreign bodies is scarce in both quality and quantity, it is likely not as rare a phenomenon as previously reported. With the Institute of Medicine's report, To Err Is Human: Building a Safer Health System, the risks of medical care in the United States have been at the forefront of public awareness.14 In response to this report, in 2006, the National Quality Forum released a list of 28 defined events that should never occur within a health care facility, with the retention of foreign bodies after surgery included in this list.15 The Leapfrog Group endorses hospitals that are willing to acknowledge these never events, with steps that include full disclosure and apology to the patient and/or family, reporting of the event to the Joint Commission on the Accreditation of Healthcare Organizations or a similar agency, root cause analysis, and waiving of all costs directly related to the event.1 Leapfrog also strongly supports Center for Medicare and Medicaid Services plan to eliminate payments for “never events.” Given the current climate, it is clear that health care facilities that do not take steps to reduce iatrogenic complications will face significant financial consequences. To reduce the number of complications such as retained sponges, it is broadly endorsed that more complete reporting of such events with root cause analysis is necessary. However, as suggested by Gibbs and Auerbach, use of an anonymous reporting system may lead to more diligent reporting without fear of litigation, and this may allow for a more accurate assessment of the incidence and causes of these events. Steps can then be made toward reducing their incidence and monitoring the efficacy of these prevention programs.