7 8 S U P P L E M E N T T O O U T P A T I E N T S U R G E R Y M A G A Z I N E O C T O B E R 2 0 1 5
years later.
• Incorrect-count retention
cases. These account for
about 20% of cases, and
people struggle to under-
stand how they happen.
Everybody knows a
sponge is missing. The
problem is that because
current counting practices
are unreliable, miscounts
— or false positives — are frequent. Missing sponges usually (about 70% to 90%
of the time) turn up in a trash receptacle in the room, or in the drapes. So when
a nurse says one is missing, the surgeon may say: There was one missing last
week, too, and it was in the trash. Check there.
Meanwhile, the surgeon keeps closing. If an X-ray is obtained, there is no
immediate read-back by radiologists, so a surgeon may read the image. But sur-
geons aren't radiologists and may not identify the sponge. Instead, the X-ray is
called negative, and even though the sponge hasn't been found, no one commu-
nicates that there's a problem. Radiologists can also misread X-rays if they don't
know what they're looking for. They may mistake the marker of a lap pad for a
Penrose drain. These cases involve faulty communication between providers.
Set up to succeed
Recognize that overall, the issue isn't bad nurses or arrogant doctors. The biggest
culprit with surgical-item retention is that nurses and surgeons continue to use
error-prone practices in unsafe cultures. Today's OR is a challenging, complex
environment. We need systems that make it easier, not harder, for fallible staffers
to get things right. The bottom line is that we need to account for the sponges, not
just count them. The mantra at the end of the case should not be, What's the
z ACCOUNTABLE CARE Keep track of all sponges that
are opened instead of counting ones that are removed.
Pamela
Bevelhymer,
RN,
BSN
