Counts Aren't Always Correct

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Barcode scanning and RFID detection help to make sure no sponge is left behind.


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."

No excuse

Sponges are sometimes found five or six years after they were left behind in patients, who often endure years of dealing with abscesses and abdominal pain. Retained sponges will eventually be found, even years later, and tracked back to the OR where it went missing.

Ms. Marsh says many retained object errors occur because physicians don't perform an all-stop and pause to check the abdomen before closing. Some nurses claim they don't have enough time to make accurate counts after surgery. Try selling that excuse to a patient or lawyer. Retained objects are indefensible. They simply shouldn't happen.

"If you follow a standardized policy, which should include manual counting and technological assistance, you're not going to have a problem," says Ms. Marsh. "At our hospital, a sponge left in the patient is considered a sentinel event, even if it's identified and removed before the patient leaves the OR."

She says barcode ID technology has made a significant difference in her team's ability to prevent retained objects. "The risk is greater when you rely on the human factor and don't support your team with technology solutions," she says.

Staff might push back against using technology, especially if it adds another step to their surgical routines, but give them time to get used to it and present them with data that support its use.

"When we showed our staff and surgeons that incidences of retained objects decreased, they bought in and knew it was the right thing to do," says Ms. Marsh. OSM

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