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Counts Aren't Always Correct
Barcode scanning and RFID detection help to make sure no sponge is left behind.
Daniel Cook
Publish Date: March 19, 2020   |  Tags:   Patient Safety
HIGH-TECH HELP Platforms designed to prevent retained objects should augment manual counts, not replace them.   |   Pamela Bevelhymer, RN, BSN, CNOR

Crack open a pack of sponges and count them before and after the procedure to make sure the same number that go into the patient also come out before the surgeon sews up the incision. Seems like a simple enough process. So why do sponges account for upwards of 70% of all retained surgical items? Perhaps because most retained sponges occur after incorrect manual counts staff assumed were accurate.

"There's always the possibility of the Swiss cheese effect — errors can occur even when several layers of preventative measures are in place," says Deb Hedrick, BSN, MA, RN, CSSM, NEA-BC, director of perioperative services at Lutheran Medical Center in Wheat Ridge, Colo. Human error is inevitable, she points out, even during the seemingly basic task of counting sponges.

That's why her eight-hospital health system invested in radio-frequency identification (RFID) ?sponge detection systems. Proprietary sponges are embedded with RFID tags, which are detected by the system's underbody mat and a wand that staff pass over patients. At the conclusion of a case, the circulator activates the detection mat, which scans the patient for tagged sponges left behind. According to the health system's policy, circulating nurses must also use the wand to check for sponges in patients with a BMI of 51 or greater. Ms. Hedrick points out the wand can also be used to scan the outside of trash cans in the OR in search of missing sponges if the manual count is off.

The technology works, but we didn't feel comfortable relying on it alone.
Valerie Marsh, DNP, RN, CNOR

Technology should augment, not replace, the manual count, says Valerie Marsh, DNP, RN, CNOR, perioperative education specialist supervisor at the University of Michigan Health System in Ann Arbor.

Nurses and surgical techs at her hospital use a barcode ID system to help confirm the accuracy of manual counts. They open a package of five sponges and use the system's touchscreen tablet to scan barcodes on each sponge to digitally document the "count in." The system captures which staff member did the scanning, the patient who is undergoing surgery and the number of sponges placed inside the patient.

To keep track of removed sponges, staff hang a counter bag on an IV pole, so its five clear pouches — matching the number of sponges in each pack — are easily visible to members of the surgical team. As sponges are removed from the patient, they're rescanned into the barcode system, which records and displays the "count out."

Staff load scanned sponges into the counting bag's pouches, starting from the bottom up. When a bag's five pouches are full, a scrub tech rolls it up and places it in the corner of the OR, where it's available for reference if the final count is off. The tech continues to hang and fill bags until each sponge has been removed from the patient, rescanned and counted.

The barcode ID system must be closed out, meaning all the sponges that were scanned into the system before the procedure were scanned back in after they were used, before the patient can leave the OR.

It's a multistep process that might seem like overkill, but Ms. Marsh views it as a patient safety double-check. "It took a while for nurses and techs to make the method part of their routines, but now it's second nature," she says. "The technology works, but we didn't feel comfortable relying on it alone. That's why we still require staff to complete a manual count."

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