KICK THE HABIT Systems that involve counting used sponges are unnecessarily challenging in a complex environment.

Much of the discussion about preventing retained surgical items focuses on communication issues between surgeons and nurses: Surgeons refuse to listen when nurses say the count is off, and nurses are too intimidated to forcefully speak up. Lack of communication can be an issue, but when it comes to surgical item retention, it's rarely the biggest problem.

In the vast majority of retained-sponge cases, nurses believe they've counted correctly, and surgeons have likely performed a sweep of the wound to make sure no sponge remains. It even gets documented in the medical record: Counts correct.

And yet there's a sponge in the patient.

The big question is why? How do so many correct counts turn out to be incorrect — 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 happen 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 understand that practices that worked in ORs decades ago are no longer reliable. Providers and their environments need to change. New practices and communication 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.

ACCOUNTABLE CARE Keep track of all sponges that are opened instead of counting ones that are removed.

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 medical record. Note that roughly 80% — the first 2 types — are the result of practice failures:

• No-count retention cases. These account for about 10% of retained-sponge cases and usually happen when no policy requires sponges to be counted and physicians don't perform wound exams. For example, most perinatal birthing rooms use gauze dressing sponges and don't have sponge-management practices. Sponges used in vaginal births should contain radiopaque markers — surgical sponges — and there should be practices to account for them. But because practices are faulty or non-existent, the vagina is the 2nd most common site for retained sponges (the abdomen is first).

The classic case is a new mother who seeks medical attention for a vaginal discharge. An exam is done, the sponge is found and thrown away, and the case goes unreported. The same can happen after pacemaker placements in cardiac cath labs. If no sponge management practice is in place, you can't expect to prevent retained sponges.

• Correct-count retention cases. These account for about 70% of all retention cases and are always surprising, because everyone thought everything was OK. Surgical counts were performed, the surgeon may have performed a sweep, and at the end of the operation, the count has been called correct. But there's a sponge in the patient. Clearly, both the surgeon and the nurses have made mistakes. And ultimately, the sponge may be found hours, days, months, or even years later.
• Incorrect-count retention cases. These account for about 20% of cases, and people struggle to understand 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 surgeons 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 communicates 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.

NEW APPROACH
10 Steps to Accounting for All Sponges

EASY MATH The Sponge ACCOUNTing System shows at a quick glance that 50 sponges were opened and 50 are accounted for.

Surgeons, nurses and radiologists are the 3 most important defenders against retained sponges, and all have specific responsibilities. The surgeon's job is to always do a methodical wound exam (MWE) before closing. The nurse's job is to keep track of the sponges added into the case and to determine with certainty that all are out at the end. The radiologist's job is to obtain X-rays in the OR when needed and to provide radiographic interpretation.

The Sponge ACCOUNTing System is a standardized, transparent, multi-stakeholder, manual sponge-management practice designed by the NoThing Left Behind project. It requires sponge holders, which are very inexpensive and widely available. Each has 2 rows of 5 pockets, so each holds 10 sponges. Here are the most important steps:

1. Keep a count of the sponges in multiples of 10 on a dry erase board everybody can see. Use a standardized format throughout all rooms in the OR suite.
2. As sponges are used and thrown into kick buckets, put them into the sponge holder, one sponge per pocket. Fill the pockets throughout the procedure. (Incidentally, pockets with blue backs are safest. With clear plastic pockets, if you have one holder in front of another, it can be hard to tell which pockets contain sponges.)
3. The surgeon must always do an MWE (not just a "sweep") before closing the wound. (This includes the vagina after any kind of vaginal procedure.)
4. At the end of the case, all used and unused sponges are put into the pockets of the sponge holders.
5. Since each holder has 10 pockets and all sponges are used only in multiples of 10, it's easy to see if a sponge is missing. There will be an empty pocket.
6. Before leaving the OR, the circulating nurse and the surgeon must look at the holders to be sure no pockets are empty. This is the "show me" step.
7. The "show me" step can also be done during the debriefing, as part of the surgical checklist.
8. The "incorrect-count checklist" should be mounted on the wall in every OR, so team members know what to do if a sponge is missing.
9. If the sponge isn't found, X-rays are obtained and a radiologist must call back to the OR after reading the image. Only a radiologist can call an image negative.
10. No stable patient leaves the OR until the sponge is found.

The NoThing Left Behind website (nothingleftbehind.org) provides additional detail and includes a policy, practice manual, training video, OR signs and posters that can be downloaded and printed.

— Verna C. Gibbs, MD

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 count? It should be, Where are the sponges? Show me! And surgeons, nurses and all other stakeholders need to be held accountable.

The Sponge ACCOUNTing System has been in place in hundreds of hospitals around the country and recently has been successful for a cohort of 30 California hospitals we've worked with. In the last 2 years, they've had zero retained sponges. The real goal, however, is not just to have zero events, but to grasp the larger meaning that zero events means zero patient harm. And that means that together we can be sure nothing is left behind.