Whatever the reason,
so-called correct-
count retention cases
account for about 70%
of the 4,500 to 6,000
cases of retained sur-
gical items reported in
the United States
every year.
The most likely
retained item? Seven
of 10 times, it's a
sponge. It's estimated that 11 patients every day are sutured up with a
surgical sponge still inside them. As retained surgical-sponge inci-
dents are often underreported, these statistics are likely low.
Then there are the near misses. A 2007 study from Brigham &
Women's Hospital in Boston found that counts are off in 1 of every 8
surgeries. In none of the study cases was an item left in a patient's
body, but the rate of faulty surgical counts is alarming.
What's clear from this muddled math is that the manual counting of
surgical sponges, sharps and instruments is susceptible to human
error and that manual counting alone is insufficient to prevent
retained sponges. The Joint Commission, the Association of
periOperative Registered Nurses (AORN) and the American College of
Surgeons recommend the use of sponge counting and detection tech-
nologies to supplement and verify the manual count.
Beyond the whiteboard
No technology can prevent medical mistakes in every situation, but
digital safety nets can be an important second line of defense against
4 8 • 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 7
• SPONGE ACCOUNTING Line kick buckets and sponge receptacles with clear
plastic bags instead of red or white ones so staff can easily see bloody used
sponges and unused sponges.
Pamela
Bevelhymer,
RN,
BSN,
CNOR
SURGICAL
ERRORS
