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Archive Staff & Patient Safety 2015

A Better Way to Eliminate Retained Surgical Items

Accounting, not counting, will ensure no sponges are left behind.

Verna Gibbs

Verna Gibbs, MD


counting used sponges KICK THE HABIT Systems that involve counting used sponges are unnecessarily challenging in a complex environment.

Much of the discussion about preventing retained surgical items focuses on communication issues between surgeons and nurses: Surgeons refuse to listen when nurses say the count is off, and nurses are too intimidated to forcefully speak up. Lack of communication can be an issue, but when it comes to surgical item retention, it's rarely the biggest problem.

In the vast majority of retained-sponge cases, nurses believe they've counted correctly, and surgeons have likely performed a sweep of the wound to make sure no sponge remains. It even gets documented in the medical record: Counts correct.

And yet there's a sponge in the patient.

The big question is why? How do so many correct counts turn out to be incorrect — errors that will harm patients? How does a "never event" become an event that happens hundreds, if not thousands, of times a year? You can reduce — or even eliminate — retained objects by using sound fundamental practices and understanding potential communication pitfalls.

A new approach
Most surgical teams are using practices that set them up to fail. The failures happen on several levels. It's never just one person's fault. But unfortunately, people tend to downplay the importance of their own roles when they know more than one person has to slip up for a mistake to happen. They need to realize that one lone action can prevent errors, as well.

Eliminating retained sponges is an uphill battle, because people tend to resist changing what appears to be working for them. But they must understand that practices that worked in ORs decades ago are no longer reliable. Providers and their environments need to change. New practices and communication strategies can — and should — be used (see "10 Steps to Accounting for All Sponges" for a breakdown of the Sponge ACCOUNTing System).

Four classes of surgical items are tracked in operating rooms: soft goods (sponges and towels), instruments, sharps, and small miscellaneous items. All can be retained. But sponges are the most common retained surgical item that unequivocally cause harm.

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