the surgical technologist
hunted through the sterile
area, checking the drapes
around the patient and the
instrument table. The
search came up empty.
They read the film.
Negative. Stating with supreme confidence that the sponge couldn't
be inside the patient if they couldn't locate it on the X-ray, they closed
up the patient. The false sense of security from an apparent negative
foreign body X-ray deceived us into discharging the patient with the
count still unresolved.
There's an important lesson: Don't put all your faith in foreign body
X-rays, which can be difficult to read, especially if the patient is obese
and in the prone position, as ours was. The neurologic wiring in place
from the Chiari malformation decompression further obstructed the
view of a sponge that's smaller than a stick of Dentyne. Had we fol-
lowed our incorrect count policy all the way through, we likely would
have found the retained object.
What should we have done?
With the count still unresolved, the OR team should have paused the
closure. The attending surgeon should have explored the wound and
pored over the X-ray once again with the radiologist. None of this hap-
pened. By the way, the sponge was spotted months later on a follow-
up film unrelated to the surgical procedure. Here are some takeaways:
• Staff won't memorize your policy. Don't expect staff to retain
what they read in your count policy. Yes, you hold in-services on
resolving incorrect counts, but that doesn't mean staff will remember
what they should do. And remember, just because someone signs off
5 6 • 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 8
The false sense of security
from an apparent negative
foreign body X-ray deceived us
into discharging the patient
with the count still unresolved.
