Archive April 2018 XIX, No. 4

Almost Left Behind

Lessons learned from a final count that came up 2 sponges short.

Frances Campbell

Frances Campbell, MSN, RN


Retained Object

The surgeon was just beginning to close the first layer of the abdomen after an exploratory laparotomy with bowel resection when we realized that we'd left 2 lap sponges inside the patient — the sponges the surgeon used to pack the wound. We had to put the patient back under and reopen to get the sponges out. The patient never left the operating room, but we were rattled by our nearest of near-misses.

How'd this happen? It wasn't due to some monumental breakdown, but a momentary lapse and staff members who were afraid to speak up. That's the thing with retained objects. They can happen when you let your guard down for just a second. We were fortunate that we caught the mistake before the patient left the OR. We'll take a near-miss over a never event.

When we investigated, we pieced together the timeline while the surgeon was closing and the nurses were counting.

SPEAK UP OR Staff wear buttons that encourage them to call for a hard stop whenever they believe patient safety is being jeopardized.

· The close. As the scrub turned her back to grab an instrument from her back table, the surgeon began closing. He grabbed a couple of sponges and put them in for packing while he was working on the bowel takedown. He then put a fish retractor on top to protect the organs from needlesticks. Trouble is, you can't see what's under the retractor. Nobody but the surgeon knew about the 2 sponges.

· The count. We had a new circulator and a timid scrub in the room. Soon after they began counting, they were interrupted by the OR team leader, who asked if they had counted, not if they had finished counting. "Yes," said the circulator and scrub, when in fact the counts weren't complete. Only the instruments had been counted. They were too intimidated to admit they'd yet to finish the final count.

We were putting on the dressings and the patient was starting to wake up when the scrub came back in the room and we discovered the counts weren't completed. They finished the count and found out they were missing the 2 laps. We notified the surgeon, who told us he packed with the sponges. We reanesthetized the patient and opened her up again to remove them.

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