A medical malpractice lawsuit currently being waged in Tennessee raises a thorny question as to who is ultimately responsible for preventing retained objects and who is at fault if they occur. The case centers on a surgical sponge left inside a patient undergoing an abdominal procedure. While the sponge was successfully removed during a second surgery weeks later, the patient's family sued the surgeon who performed the procedure for negligence. The surgeon argued that he was not liable for the retained object, maintaining that his primary responsibility was the procedure itself and that he relied on the attending nurses to conduct the surgical count before he closed the incision — a count that, in this case, was incorrect.

However this case is resolved in the eyes of the law, what it makes clear is how vigilant you must be in following safeguards designed to prevent patients from leaving your ORs with more than suture in the surgical site.

1. Follow the standards. Adopt and train surgical staff to comply with AORN's recommended practices for counting surgical items and taking action when there is an incorrect count. In summary, AORN says that when a count is incorrect, an additional count should be immediately undertaken, and if the additional count is also incorrect, the patient should be X-rayed before the case is concluded.

2. Know what's on the table. Develop a reliable process by which your staff can ensure accurate, and surgeon-specific, physician preference cards. The surgical objects most commonly retained include sponges, towels, hand-held instruments and their components and sharps, including pieces of wire. They're not the only items that can be left behind, though. Nurses must count any specialized items or items added late to a case, and keep preference cards — which are valuable indicators of the range of objects used in a case — accurate through post-op discussions with the surgeon. At the end of every case, during the surgeon's debriefing with his staff, the preference card should be reviewed and changed if any items are regularly added or go unused during a case.

3. Keep it visible. Mandate the use of radiopaque surgical sponges within the surgical wound. The fluoroscopically detectable marker woven into the material can assist in locating a missing sponge in the event of incorrect counts. Also prohibit the use of towels in the wound that don't include radiopaque markers. Several manufacturers presently market a system that utilizes sponges equipped with radiofrequency identification tags or chips along with scanning hardware to ensure that the sponges don't elude collection. While this technology may prove valuable, the task of preventing retained objects ultimately rests in the hands and eyes of the surgical team.

4. Take one last look. The surgeon should conduct a thorough wound exploration before closing the surgical site. In abdominal procedures, the stomach and bowel should be moved aside to see if a foreign object has become buried or lodged beneath the organs. While the abdomen is the body's largest cavity, abdominal cases aren't the only ones demanding due diligence. OB-GYN surgeries also present heightened risks for retained objects. A sponge might be left behind after throat surgery, and even ears and noses might retain small objects following ENT cases.

5. Count correctly. Surgical counts should be done audibly, between the circulating nurse and the scrub nurse. That way, a second set of eyes and ears observes the process and is in agreement or notes any errors. On larger cases in which several layers are to be closed, more than one closing count may be necessary. In any case, verify with an audible final count before the patient leaves the OR.

6. Control the count. Counts should always begin at the surgical site, proceed to the Mayo stand and conclude at the discarded items. This standardized sequence, from sterile to contaminated areas, lets you determine which items are currently in use, which may still be used and which will not be used again. Make sure the surgeon knows — especially if you count with your back to the surgical site — that if he needs an item from the stand during the count, he must ask for it and not reach for it himself. Then the counters will know it has been removed, and missing items will not be uncounted and potentially left behind.

7. Maintain consistency. Since misinformation can lead to miscounts and surgical errors, make a rule restricting staff changes during critical points in a procedure. For instance, unless it is absolutely necessary, avoid any staff changes in the OR during the last few minutes of a case as the pre-closing count is about to start. For certain types of surgeries, physicians may demand no personnel changes at all for the duration of the case.

8. Check and double-check. Reconcile any surgical counts that have been conducted before additional procedures are begun or the surgical team sees a mid-case change. The hard-and-fast rule is, if you start counting, you finish counting. If you enter the OR to relieve a colleague, however, she may have already done a preliminary count. Be sure to confirm this yourself. Anyone who joins a surgery in progress should carry out a recount after receiving the handoff report, and report any changes (such as more sponges added to the case) that may have occurred by the time replaced personnel return.

9. Add it up. If a count is discovered to be incorrect, bring it to the surgeon's attention. All wound closure activities should stop immediately. Conduct a second count and thoroughly search the OR environment. If the second count is also incorrect and the search turns up nothing, provide a description of the missing item and X-ray the operative field. If the item is found, initiate a new count to confirm the finding. If it is not, close the patient and document the number of counts conducted, the surgeon's visual sweep and fluoroscopic imaging, searches of the trash bin (using clear bags in kick buckets helps to facilitate the identification of discarded items) and all other attempts to reconcile the discrepancy.