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.
• 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 count-
ing. "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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