LOST AND FOUND X-ray detectable sponges are sometimes easier to spot in the surgical wound.

A cannula fragment was discovered in a patient's knee 6 years after his arthroscopy. A surgical sponge was found lodged in a patient's abdomen 4 years after her hysterectomy. A gastric band was detected during a sleeve gastrectomy conversion. Every year, an estimated 4,500 to 6,000 cases of retained surgical items are reported in the United States: soft goods, sharps, instruments and small miscellaneous items.

The manual counting of surgical sponges, sharps and instruments is susceptible to human error; that's why we haven't been able to eliminate retained objects. Items are left behind most frequently in the abdomen and pelvic areas, from where they can migrate to the intestine, bladder, thorax and stomach. The consequences can be devastating. Retained surgical items can result in reoperation to remove the missing object, post-op infection and, in rare cases, even death.

Retained items generally involve a deviation from routine counting practice caused by distractions, excess noise, time pressures, multi-tasking, fear of speaking up or poor teamwork. Your surgical team members must work together to develop a standardized, transparent, verifiable and reliable counting protocol — and then hold each other accountable to following it. Active participation in the process improves communication and teamwork. You must first define the roles and responsibilities each team member has in the counting process.

Circulating nurses. They must ensure there are no counted items remaining in the OR from the previous case as they set up the room. They then perform the initial count, with help from a scrub tech, by noting the number of soft goods, sharps and miscellaneous items on a whiteboard in the OR for everyone on the team to reference. They can never assume that counts indicated on packaged supplies are correct and must count out individual items before documenting the initial tally. If extra supplies are opened during the procedure, circulating nurses should update the count noted on the whiteboard.

ZONE OUT Circulating nurses and scrub techs should perform initial and closing counts in areas that are free from distractions.

Scrub techs. They must maintain an organized sterile field and have an ongoing awareness of where counted items are during surgery. There are documented reports of instrument fragments remaining in patients after surgery, so surgical techs must also inspect all instruments and make a mental note of their condition so they can recognize if screws or parts are missing when the surgeon returns them after use. At the end of the case, the scrub tech teams with the circulating nurse to perform the closing count.

Surgeons. They must ensure they use only radiopaque items in the wound, maintain an awareness of those items in the surgical field and communicate with the surgical team about which items are being placed in the patient. At the end of the case, and before closing, the surgeon should perform a methodical visual sweep of the wound and feel around to ensure no items remain. The surgeons should also notify other team members if items are intentionally left in the wound as packing material. They should verify and document the results of the final count.

Anesthesia providers. They should coordinate their care so as to not rush the surgical team through the counting process. For example, the patient shouldn't be emerging from anesthesia when the count is underway. Anesthesia providers must also be responsible for accounting for and removing throat packs and bite blocks, which are both surgical items that have been left in patients. Here's a suggestion: Have anesthesia providers wear a wristband that notes "Throat Pack" or "Bite Block" as reminders to remove the items before patients leave the OR.

Additional help
Detection and counting technologies — handheld scanners that count sponges affixed with 2D matrix labels or wands that locate sponges by radiofrequency identification — supplement the manual counting process. They offer such potential benefits as timelier counts, improved count accuracy and less usage of post-op imaging to locate missing items. Have your entire surgical team assess each technology option to see which one would effectively augment their counting practices.

Minimizing distractions during initial and closing counts is one of the best ways to prevent retained items. It's best to create a "no interruption" zone, where nurses and surgical techs conducting counts are left to focus only on the task at hand. The initial count should take place in the relatively quiet few minutes before the patient enters the room. If that's not possible, a second nurse could assist with patient positioning and induction while the primary circulating nurse focuses her complete attention on the initial count. That simple step minimizes multi-tasking and distractions during this critical time.

And don't try to remember and count at the same time. A good practice is to record one count before starting the next. Studies show that when our brains switch between counting and remembering, we make transcription errors.

Empower team members to speak up when one of their colleagues is creating a distracting environment with unnecessary talking or by playing music over the OR's sound system. Some facilities have even flashed "initial count in progress" on surgical monitors to alert the rest of the team to keep distractions at a minimum. OSM

WHEN COUNTS ARE OFF
In the Event of a Surgical Count Discrepancy ...

ALL HANDS ON DECK Each surgical team member should help to resolve count discrepancies.

A 2007 study from Brigham & Women's Hospital in Boston found that counts are off in 1 out of every 8 surgeries. In none of the cases was an item left in a patient's body, but that's still a surprisingly high number. Here's how to respond when there's a discrepancy between the initial and closing counts.

Communicate. The circulating nurse or scrub tech must immediately notify the rest of the team by identifying the type and number of items that are unaccounted for. They should receive verbal confirmation from the surgeon that he understands items are missing.

Suspend wound closure. The surgeon suspends wound closure and performs another methodical wound exploration while the anesthesia provider coordinates the patient's emergence (if possible) so that the surgical team is not rushed through the process of locating the missing items.

Conduct all-in search. The circulating nurse calls for assistance from everyone in the room and works with the scrub person to organize the counted items and search the field for the missing item. All team members must remain in the OR in case the missing item is stuck to their shoes or clothing and so they can help in the search.

Recount. If you find the item, include it in a recount. If the recount is correct, wound closure can resume.

Perform an intraoperative X-ray. When the item remains missing, the surgeons and a radiologist can perform an intraoperative X-ray to determine if it's still in the surgical wound. If the X-ray locates the item, the surgeon assesses the risks and benefits of going back in to remove it.

If the item is still missing after the X-ray is performed, the surgeon must speak with the patient about the health risks involved and the options for follow-up care.

Conduct a root cause analysis. A root cause analysis is required whenever a retained surgical item occurs, but it's also a good idea to perform one after near-misses in order to assess system errors and find out exactly what went wrong. Were surgical team members distracted? Why didn't someone speak up? The goal is to improve protocols that would prevent a similar mistake from occurring — or almost occurring — again.

— Mary C. Fearon, MSN, RN, CNOR