small sponge had been left in the patient's lower left abdomen, accord-
ing to the California Department of Public Health.
An autopsy suggested that the man's death had been caused by several
things, including peritonitis, or inflammation of the tissue lining the
abdomen and covering abdominal organs, prompted by the sponge's
prolonged presence in the patient's body.
It appears the hospital had followed its counting procedure, which
states that "all sponges will be placed in the appropriate holders
before the patient leaves the room. The physician must verify with the
circulating RN that all holder pockets are filled and match the number
on the dry-erase board."
The nurse and scrub technician who performed the counts in their
usual manner told investigators that the pocketed sponge bag that
was hung to place used sponges in had a partition that divided it
down the middle. It had 2 slots on each side with 5 sections and could
hold a total of 10 lap sponges, 1 sponge for each slot. She stated if the
partition had become separated, 1 sponge could have covered 2 slots
and looked like 2 sponges instead of 1.
In light of the incident, the nurse said they are now rolling the
sponges so they fit the sponge holding bag better and making sure the
ties for each sponge hang down. Each lap sponge has a blue tie
approximately 7 inches long for the purpose of being visible when a
patient is X-rayed. The X-ray-detectable marker is now placed where
the team can see and count it (osmag.net/bEg4HP).
Beyond the count
Is it any wonder that The Joint Commission estimates that current prac-
tices for counting sponges have a 10% to 15% error rate? We still prac-
tice audible and visible counts faithfully, and we use a whiteboard sys-
tem to keep track of our counts. Sponge-detection technology can add
9 2 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • J U L Y 2 0 1 9