AORN Journal
Volume 83, Issue 2 , Pages 418-433 , February 2006

Recommended Practices for Sponge, Sharps, and Instrument Counts

Notes 

  1. In:  Beyea SC editors. Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary . second ed.. Denver: AORN, Inc; 2002;
  2. Murphy EK . “Operating room records, counts cause concern,” (OR Nursing Law) . AORN Journal . June 1990;51:1606–1612
  3. Zuffoletto J . “Nurses' vs surgeons' responsibility for sponge counts”, (OR Nursing Law) . AORN Journal . June 1993;57:1457–1458
  4. ECRI  . ”Sponge and instrument counts,” (Risk Analysis, Surgery and Anesthesia 5) . Healthcare Risk Control . January 1996;4:1–9
  5. Gwande AA , et al.   “Patient safety: Risk factors for retained instruments and sponges after surgery” . The New England Journal of Medicine . January 2003;348:229–235
  6. Murphy EK . “‘Captain of the ship’ doctrine continues to take on water,” (OR Nursing Law) . AORN Journal . October 2001;74:525–528
  7. “Surgical nurses: Sponge count is strictly nurses' responsibility, court rules” . Legal Eagle Eye Newsletter for the Nursing Profession . September 2000;8:2
  8. Golinski v Hackensack Medical Center, Conley, Irani, Archer, Bruno, and Del Rosario, 298 NJ Super 650; 690 A2d 147; 1997 NJ Super (New Jersey, 1997).
  9. Stafford v Molinoff and Halfen, 228 AD2d 662; 645 NYS2d 313; 1996 NY App Div (New York, 1996).
  10. Ram v Vaughn and Foxworthy v Athens-Limestone Hospital v Coates, 662 So2d 218; 1995 (Alabama, 1995).
  11. Rozovsky LE , Rozovsky FA . “The surgeon and the nurse share the blame: A case of a retained sponge” . Canadian Operating Room Nursing Journal . September/October 1991;9:20–21
  12.  Tammelleo AD “The surgeon's nondelegable responsibility for the sponge count” . The Regan Report on Nursing Law . July 1997;38:2
  13. Beyea SC . “Counting instruments and sponges,” (Patient Safety First) . AORN Journal . August 2003;78:290–294
  14. Cherry JK . “Surgery: Foreign object retention,” The Doctors Company . http://www.thedoctors.com/risk/specialty/generalsurgery/J4219.asp (accessed 8 Sept 2005)
  15. Murphy EK . “Nurses' liability for inaccurate counts,” (OR Nursing Law) . AORN Journal . April 1990;51:1067–1069
  16. Murphy EK . “Liability for inaccurate counts; assistant circulators,” (OR Nursing Law) . AORN Journal . January 1991;53:157–161
  17. Institute of Medicine  . Crossing the Quality Chasm: A New Health System for the 21st Century . Washington, DC: National Academy Press; 2001;
  18. Kaiser CW , et al.   “The retained surgical sponge” . Annals of Surgery . July 1996;224:79–84
  19. Gibbs VC . “Did we forget something? Retained surgical sponge,” AHRQ Web M&M: Case and Commentary . http://www.webmm.ahrq.gov/case.aspx?caseID=27&searchStr=%22retained+surgical+sponge%22+AND+Gibbs (accessed 8 Sept 2005)
  20. Lauwers PR , Van Hee RH . ”Intraperitoneal gossypibomas: The need to count sponges” . World Journal of Surgery . May 2000;24:512–527
  21. Zbar AP , et al.   “Gossypiboma revisited: A case report and review of the literature” . Journal of the Royal College of Surgeons of Edinburgh . December 1998;43:417–418
  22. Hemelt BA , Finan MA . “Abdominal sacral colpopexy resulting in a retained sponge: A case report” . The Journal of Reproductive Medicine . November 1999;44:983–985
  23. Kim SR , Baik HK , Park YW . “Retained surgical sponge presenting as a pelvic tumor after 25 years” . International Journal of Gynecology and Obstetrics . August 2003;82:223–225
  24. Nomori H , et al.   “Retained sponge after thoracotomy that mimicked aspergilloma” . Annals of Thoracic Surgery . May 1996;61:1535–1536
  25. Dhillon JS , Park A . “Transmural migration of a retained laparotomy sponge” . The American Surgeon . July 2002;68:603–605
  26. Cruz RJ , et al.   “Intracolonic obstruction induced by a retained surgical sponge after trauma laparotomy,” (Case Reports) . Journal of Trauma . November 2003;55:989–991
  27. McLeod RS , Bohnen JM . “Canadian Association of General Surgeons evidence based reviews in surgery 9: Risk factors for retained foreign bodies after surgery” . Canadian Journal of Surgery . February 2004;47:57–59
  28. Eskreis-Nelson T . ”Medical errors and the need for nurses' continuing education,” (Nursing Case Law Update) . Journal of Nursing Law . 2000;7:49–59
  29. New York State Department of Health  . ”Retained surgical sponges,” New York Patient Occurrence Reporting and Tracking System . NYPORTS News & Alert . September 2002;11: Also available at http://www.health.state.ny.us/nysdoh/hospital/nyports/annual_report/2000–2001/news_and_alerts.htm (accessed 8 Sept 2005)
  30. Fogg D . “Retrieving flash sterilized items; occupational exposure to bloodborne pathogens; sponge, needle, and instrument counts”, (Clinical Issues) . AORN Journal . April 1992;55:1091–1093
  31. Reason J . “Safety in the operating theater—Part 2: Human error and organisational failure” . Quality and Safety in Health Care . February 2005;14:56–60 Also available at http://qhc.bmjjournals.com/cgi/search?andorexactfulltext=and&resourcetype=1&disp_type=&sortspec=relevance&author1=reason&fulltext=&volume=14&firstpage= (accessed 8 Sept 2005)
  32. ECRI  . ”Retained foreign object: Surgeon admits liability” . Operating Room Risk Management . March 2003;15–16
  33. Gencosmanoglu R , Inceoglu R . “An unusual cause of small bowel obstruction: Gossypiboma—Case report” . EMC Surgery . September 2003;3:1–6 Also available at http://www.biomedcentral.com/1471–2482/3/6 (accessed 8 Sept 2005)
  34. ECRI  . ”Locating ‘lost’ neurosurgical sponges, (Risk Analysis, Surgery and Anesthesia 5.1) . Healthcare Risk Control . January 1996;4:1–2
  35. Henry S . “Damage control in 2001: Who, when, and how” . Trauma Quarterly . 2002;15:121–137
  36. “Recommended practices for environmental cleaning in the surgical practice setting” . In: Standards, Recommended Practices, and Guidelines . Denver: AORN, Inc; 2005;p. 361–366
  37. “Recommended practices for standard and transmission-based precautions in the perioperative practice setting” . In: Standards, Recommended Practices, and Guidelines . Denver: AORN, Inc; 2005;p. 447–451
  38. Occupational Health and Safety Administration  . ”Occupational exposure to bloodborne pathogens; needlestick and other sharps injuries; final rule” . federal Register . Jan 18, 2001;66:5317–5325 Also available at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=16265 (accessed 8 Sept 2005)
  39. Berguer R , Heller PJ . “Preventing sharps injuries in the operating room” . Journal of the American College of Surgeons . September 2004;199:462–467
  40. Perry J , Parker G , Jagger J . ”EPINet Report: 2001 percutaneous injury rates” . Advances in Exposure Prevention . 2003;6 no 3:32–36
  41. Fogg D . “Gas sterilizing medication; using wall suction for evacuating laser plumes; counting needles in multipacks”, (Clinical Issues) . AORN Journal . August 1990;52:408–412
  42. Peterson C . “Rectifying counts; neurostimulators; double gloving; reprocessing single-use devices; simultaneous counting”, (Clinical Issues) . AORN Journal . September 2002;76:510–515
  43. Peterson C . “Deep vein thrombosis; neutral zone; circulating and recovering; environmental controls; wound classifications; sterile field”, (Clinical Issues) . AORN Journal . April 2004;79:856–864
  44. Mendez LE , Medina C . “Late complication of laparoscopic salpingoophorectomy: Retained foreign body presenting as an acute abdomen” . Journal of the Society of Laparoendoscopic Surgeons . January-March 1997;1:79–81
  45. ECRI  . ”Safe use and selection of trocars,” (Risk Analysis, Surgery and Anesthesia 25) . Healthcare Risk Control . July 1999;4:1–15
  46. Thomas EJ , Moore FA . “The missing suction tip”, AHRQ Web M&M: Case and Commentary . http://www.webmm.ahrq.gov/case.aspx?caseID=37&searchStr=%22spotlight+cases%22 (accessed 8 Sept 2005)
  47. Milanokov M , Dragan S , Miljkovic N . ”Broken blade in the knee: A complication of arthroscopic meniscectomy” . Arthroscopy: The Journal of Arthroscopic and Related Surgery . January 2002;18:1–3
  48. Tammelleo AD . “Were nurses liable for clamp left in cardiac patient?” . The Regan Report on Nursing Law . July 1999;40:1
  49. Smith C . “Surgical tools left in five patients” . Seattle Post-Intelligencer . 8 Dec 2001; http://seattlepi.nwsource.com/local/49883_error08.shtml (accessed 8 Sept 2005)
  50. “Recommended practices for cleaning and caring for surgical instruments and powered equipment” . In: Standards, Recommended Practices, and Guidelines . Denver: AORN, Inc; 2005;p. 395–403
  51. “Recommended practices for cleaning and processing endoscopes and endoscope accessories” . In: Standards, Recommended Practices, and Guidelines . Denver: AORN, Inc; 2005;p. 341–346
  52. “Retained foreign bodies: Reducing the risks”, Self-Insurance Program: Risk Management and Loss Prevention (revised April 2004), University of Florida . http://www.riskmanagementeducation.com/brochures/Retained%20Foreign%20Bodies.pdf (accessed 8 Sept 2005)
  53. Barrow CJ . “Use of x-ray in the presence of an incorrect needle count,” (Clinical Innovations) . AORN Journal . July 2001;74:80–81
  54. Macilquham MD , Riley RG , Grossberg P . “Identifying lost surgical needles using radiologic techniques” . AORN Journal . July 2003;78:73–78
  55. B A Liang. “The adverse event of unaddressed medical error: Identifying and filling holes in the health-care and legal systems,” Symposium: Patient Injury, Medical Errors, Liability and Reform, The Journal of Law, Medicine and Ethics 29 no 3–4 (Fall/Winter 2001) 346–368.
  56. Dunn D . “Incident reports—Their purpose and scope”, (Home Study) . AORN Journal . July 2003;74:45–68
  57. Wald H , Shojania KG . “Root cause analysis”, in Making Health Care Safer: A Critical Analysis of Patient Safety Practices, Agency for Healthcare Research and Quality (Evidence Report/Technology Assessment, Number 43, AHRQ Pub 01-E058) . Also available at http://www.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf (accessed 8 Sept 2005)
  58. “Root cause analysis”, VA National Center for Patient Safety . http://www.patientsafety.gov/tools.html (accessed 8 Sept 2005)
  59. ECRI  . ”Perioperative documentation,” (Risk Analysis, Surgery and Anesthesia 7) . Healthcare Risk Control . January 1996;4:1–4
  60. “Recommended practices for documentation of perioperative nursing care” . In: Standards, Recommended Practices, and Guidelines . Denver: AORN, Inc; 2005;p. 321–323

 Originally published May 1976, AORN Journal, as “Standards for sponge, needle, and instrument procedures.”Format revision March 1978, July 1982.Revised March 1984, March 1990.Revised November 1995; published October 1996, AORN Journal.Revised; published December 1999, AORN Journal. Reformatted July 2000.

PII: S0001-2092(06)60172-5

doi: 10.1016/S0001-2092(06)60172-5

AORN Journal
Volume 83, Issue 2 , Pages 418-433 , February 2006

Article Tools