O C T O B E R 2 0 1 5 O U T P A T I E N TS U R G E R Y. N E T 7 5
no sponge remains. It even gets documented in the medical record: Counts cor-
rect.
And yet there's a sponge in the patient.
The big question is why? How do so many correct counts turn out to be incor-
rect — errors that will harm patients? How does a "never event" become an
event that happens hundreds, if not thousands, of times a year? You can reduce
— or even eliminate — retained objects by using sound fundamental practices
and understanding potential communication pitfalls.
A new approach
Most surgical teams are using practices that set them up to fail. The failures hap-
pen on several levels. It's never just one person's fault. But unfortunately, people
tend to downplay the importance of their own roles when they know more than
one person has to slip up for a mistake to happen. They need to realize that one
lone action can prevent errors, as well.
Eliminating retained sponges is an uphill battle, because people tend to
resist changing what appears to be working for them. But they must under-
stand that practices that worked in ORs decades ago are no longer reliable.
Providers and their environments need to change. New practices and commu-
nication strategies can — and should — be used (see "10 Steps to Accounting
for All Sponges" for a breakdown of the Sponge ACCOUNTing System).
Four classes of surgical items are tracked in operating rooms: soft goods
(sponges and towels), instruments, sharps, and small miscellaneous items.
All can be retained. But sponges are the most common retained surgical item
that unequivocally cause harm.
In 2004, I helped start NoThing Left Behind (nothingleftbehind.org), a national
surgical patient-safety project aimed at preventing retained surgical items. We've
studied more than 200 retained-sponge cases, and have seen that they can be
classified into 3 types of cases, based on how the count was recorded in the
