AORN Journal
Volume 87, Issue 2 , Pages 315-321, February 2008

Counting Difficulties: Retained Instruments, Sponges, and Needles

  • Sarah Jackson, RN

      Affiliations

    • Sarah Jackson, RN, is a circulating nurse at Harry S. Truman Medical Center, Columbia, MO. Ms Jackson has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
    • ,
  • Sharon Brady, RN, CNOR

      Affiliations

    • Sharon Brady, RN, CNOR, is a same day surgery nurse at University of Missouri Hospital, Columbia. Ms Brady has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.

Article Outline

ABSTRACT 

PATIENTS IN WHOM A SPONGE or instrument is left after surgery may suffer complications including pain, infection, abscess, or intestinal obstruction.

CONSEQUENCES OF RETAINED ITEMS for surgical team members may include malpractice lawsuits and adverse actions from the National Practitioner Data Bank and state licensing board.

ADHERENCE TO AORN recommended practices for counting and facility counting policies can protect both patients and practitioners. AORN J 87 (February 2008) 315-321. © AORN, Inc, 2008.

 

According to a recent study, retention of surgical sponges and instruments after surgery may occur as often as once in 100 procedures or as infrequently as once in 5,000 procedures.1 The American College of Surgeons has stated that one incidence of a retained item after surgery occurs at least once a year in any hospital at which 8,000 to 18,000 major procedures are performed annually.1 Retained items may be located by x-ray or found during a subsequent exploratory surgical procedure. Patients in whom a sponge or instrument is left after surgery may suffer complications such as

•pain,

•infection,

•a granulomatous response with an abscess,

•fistula formation, or

•intestinal obstruction.

Clamps, needles, and retractors can cause organ damage, bowel perforation, sepsis, severe pain, and even death.2

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Reasons Items Are Left Behind 

The problems associated with surgical counts are varied. Initial counts performed by a surgical team may be inaccurate for a number of reasons. For example, the count may be hurried or the sponges may not be separated when opened, so the actual number on the field may not be correct. Counts occur at inopportune times for the surgical team, including shift changes when new staff members replace original staff members and at the end of the operative procedure. A procedure generally does not stop for the count, so the circulating nurse and scrub person continue to perform many tasks while they are counting. Large surgical teams make many requests that distract from the count. For example, the anesthesia care provider may ask the circulating nurse for supplies or assistance at the end of the procedure.

During long procedures, surgical team members may take lunch or a break. Items added to the field during these breaks may inadvertently be left out of the count. The original team members may not know or remember that items were added, resulting in an incorrect final count.

Patients who are obese, have emergency surgery, or have unplanned changes to the originally planned procedure (ie, conversion from an laparoscopic approach to an open procedure) are at increased risk of retaining an item.1 Patients with traumatic injuries who are having surgery involving more than two surgical services or those who are having lengthy procedures also are at a greater risk.1 It is important for the circulating nurse and scrub person to know this and take extra precautions with the counts in these cases.

If an incorrect count occurs, inequities of power between surgical team members may be difficult to overcome. For example, the surgeon may insist on accepting the wrong count without re-exploring the wound or allowing an x-ray to be taken to verify that the missing item is not in the patient.

Although incompetent health care providers exist and certainly can cause incorrect counts to occur, the majority of count problems occur because of a systems failure that needs to be identified and analyzed to establish how and where the failure occurred. Counting policies should be reviewed when there is a near-miss situation and when there has been an occurrence of a retained item at the facility. There are instances in which individuals on the surgical team may be found negligent if they are not performing their counting duties properly. In that situation, the system has failed and the team members may be negligent as well.

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Legal Ramifications for Surgical Team Members 

In the event of a retained item during surgery, surgical team members probably will be involved in a lawsuit and may have to pay damages to the patient or his or her family members. A lawsuit filed by a patient or family member against a hospital or health care provider is classified as a tort.3 In order to win a judgment in this type of case, the plaintiff or the person who filed the suit must establish four conditions:

1.A legal duty existed between the caregiver and the patient.

2.The caregiver failed to conform to the relevant standards of care. Standard of care is proved by an expert witness, existing standards of practice, or by obvious errors as covered by the doctrine of res ipsa loquitur (ie, the thing speaks for itself).

3.The breach caused an injury.

4.The caregiver's failure caused damage that can be either pecuniary (ie, monetary4) or nonpecuniary (eg, emotional distress, pain, suffering). Damages may be compensatory (ie, an appropriate and counterbalancing payment5) and may also include punitive damages (ie, awarded in excess of compensation to the plaintiff to punish a defendant for a serious wrong6). Punitive damages are only awarded in the event of wanton and reckless conduct.3

The National Practitioner Data Bank (NPDB) was established by Congress to monitor the occurrence of medical malpractice and to improve health care quality by identifying and disciplining incompetent physicians, nurses, and dentists.7 According to the NPDB 2005 annual report, a total of 586 professional nurse malpractice payments were awarded with a mean payment of $319,905 and a median payment of $100,000. The report noted 446 surgery-related malpractice payments with a mean payment of $148,716.8 Count-related errors were included, but they were not specifically delineated in the report. The report identified 52 surgery-related cases that involved RNs in which the mean payment for the lawsuit was $124,505 and the median payment was $60,000.8

There have been a total of 5,575 reports against nurses in the United States since the creation of the NPDB in 1990.9 The reporting of nurses to the NPDB continues to rise because the public has become more aware of errors that can occur during surgical procedures, and hospitals are more willing to send queries to the NPDB now than ever before.

Reporting of RNs to their state's Board of Nursing also is occurring in many states. Institutions have policies regarding negligence (eg, leaving items in patients after surgery). If a nurse is reported to his or her state board by the NPDB, the case is investigated and the state board decides whether discipline is necessary. Discipline can include suspension or revocation of a license for a period of time that is determined by the board, during which the nurse is monitored by the board and the managers at the workplace. During this monitoring period, the nurse may be required to take continuing education courses with an emphasis in the area in which the malpractice occurred. Physicians and dentists also are subject to the same type of discipline, including restriction on treatment of and billing for Medicare and Medicaid patients.9 Adverse actions taken against the nurse, physician, or dentist by the NPDB in collaboration with the practitioner's state licensing board can involve

•revocation of licensure,

•limitation or removal of clinical privileges,

•exclusion from Medicare and Medicaid programs, and

•exclusion from professional society membership.

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AORN Recommended Practices for Counts 

AORN's “Recommended practices for sponge, sharp, and instrument counts,”10 is designed to facilitate correct counts and should be used in conjunction with institutional policies. The recommended practices state that sponges should be counted for all procedures in which the possibility exists that a sponge could be retained.10 The circulating nurse and scrub person should count sharps and miscellaneous items for all procedures and should count instruments for all procedures in which the likelihood exists that an instrument could be retained. The circulating nurse should document on the patient's intraoperative record that sponge, sharps, and instrument counts occurred and the status of those counts.

The “Recommended practices for sponge, sharp, and instrument counts,” has been updated four times since it was developed in 1976. Its use is widespread and nationally recognized as the gold standard for counting policies in the United States.11 Perioperative managers should ensure that facility policies and procedures for sponges, sharps, and instrument counts are developed and then reviewed annually according to institutional policy.11 Nurses are advised to review the recommended practices and their facility policy annually and to make adjustments to their practice as necessary.10

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Institutional Policies for Counting 

Perioperative managers should ensure that the facility policy for counting provides explicit directions for the actions that staff members should take if a counting discrepancy occurs. The policy should direct staff members to obtain an x-ray if a sponge or an item that contains a radiopaque marker cannot be located during a count. An x-ray will not always reveal a retained item, but the majority of items will be identified.

An example of a policy for incorrect counts might state that the circulating nurse will perform the following actions:

•notify the surgeon and anesthesia care provider of the item missing and notify the direct supervisor for additional staffing support;

•request that the surgeon and scrub person search the wound, sterile field, and immediate area;

•ensure that all linen and trash bags are searched and previously bagged sponges are recounted; and

•perform a repeat count of the items when the missing one is located (eg, if the “misplaced” sponge is thought to be located, all sponges of that type are recounted).

The scrub person will organize the sterile field for a thorough search and repeat any count as requested.

Surgeons should be included in the policy development process because it is vital to have their “buy in” to the count policy. This will help to ensure that all team members understand the importance of and cooperate during the count process. Some facilities have enlisted a surgeon to be the count policy project “champion” to help disseminate information regarding the count policy to all the surgeons who have privileges at the facility. The surgeon champion can involve other surgeons to act as peers regarding adherence to the policy. It is the responsibility of the surgical chief of staff to determine and implement sanctions for uncooperative surgeons.

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Failed Recovery Process 

In the event that the missing item is not found, the surgeon decides whether to continue with closure. The circulating nurse

•confirms with surgeon what item is missing,

•calls for an x-ray to be taken,

•notifies the Radiology Department that the purpose of the x-ray is to determine whether an item has been retained in the patient,

•informs the Radiology Department whether a radiologist will be needed to read the x-ray immediately,

•completes the x-ray requisition noting in large letters the purpose of the x-ray on the top of the form, and

•completes the necessary documentation in the appropriate charting areas on the patient's medical record.

The circulating nurse notifies the direct supervisor immediately of any requests for a deviation in policy by any member of the surgical team.

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Case Study 

The following case study is a hypothetical situation that could occur at any facility. Mr T is a large man undergoing a coronary artery bypass graft procedure with four-vessel bypass. The procedure starts at 8 AM. The primary circulating nurse and scrub person are relieved for lunch between 11:45 AM and 1:15 PM; their shifts end at 4:30 PM. The procedure is completed at 6 PM. The preliminary counts were noted to be correct, but during the final count, the relief circulating nurse and scrub person determine that a laparotomy sponge is missing.

The circulating nurse notifies the surgeon and members of the surgical team that a sponge is missing from the count. The laparotomy sponge is not located even after the surgical team performs repeated counts and searches. The circulating nurse calls the Radiology Department and requests a chest x-ray, notifying the Radiology Department receptionist that the purpose of the x-ray is to locate a missing laparotomy sponge. She then completes the radiology request form, noting the purpose of the x-ray. The x-ray is taken at the end of the procedure, and after reading the x-ray, the surgeon determines that the missing sponge is not revealed by the x-ray. The circulating nurse completes a variance report indicating there was an incorrect count at the conclusion of the procedure.

The circulating nurse, anesthesia care provider, and surgeon transport Mr T to the intensive care unit (ICU) where the ICU nurse notes that the patient is experiencing arrhythmias; has poor to absent peripheral pulses; and is demonstrating signs of poor organ perfusion (eg, electrolyte imbalances, abnormal arterial blood gases, acidosis, poor urine output, hypotension without dopamine or other medications).

By evening, Mr T's condition remains unchanged, so the surgeon takes Mr T back to the OR and performs a repeat thoracotomy. After a thorough search of the thoracic cavity, the surgeon discovers the missing laparotomy sponge. After the surgeon removes the sponge, Mr T's heart begins beating regularly and his condition improves. Mr T is released from the hospital a week later with no further complications.

After reviewing the incident, team members note that the chest x-ray taken at the conclusion of the first procedure was of poor quality. The team also notes that the patient was a large man with a large chest. The laparotomy sponge may not have shown up on the x-ray because of the density of the patient's heart and chest and the poor x-ray quality.

This incident emphasizes the fact that x-rays do not always reveal retained items, even laparotomy sponges. Of particular importance in this situation is that the incident might have been avoided if the surgeon had explored the chest cavity again before closing. Furthermore, the surgeon reviewed the x-ray film himself rather than having a radiologist review the film, which may have caused an incomplete, inadequate, or misread interpretation of the intraoperative x-ray.

In addition to the preceding problems, the team notes that many distractions occurred during the procedure that could have led to a wrong count (Figure 1). The common distracters in this case study were fatigue, repeated telephone calls and pages on staff members beepers, numerous items added to the field during the procedure, change and relief of staff members, and anesthesia care providers requiring assistance.

Each OR procedure has its own set of distracters. It is imperative that the surgical team members do their utmost to ensure the safety of the patient during counts, particularly because of the sometimes unavoidable distractions that occur in the OR.

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Methods to Prevent Incorrect Counts 

Counting is a process that lends itself to errors because of variables that may not be controllable during surgery, and errors occur more frequently when no definitive counting policy is in place. Litigation regarding retained items in a patient is “nearly indefensible.”10(p293) All members of the surgical team must be accountable and diligent about the count process.

Staff members should adhere to AORN standards for counting along with the facility's policy regarding counts and incorrect counts. In a large number of situations where an item is retained in a patient, the preliminary surgical count appeared to be correct but was in fact incorrect, leading to an incorrect closing count. Ensuring that all sponges are separated and opened and visually observing needles would help ensure that preliminary and add-on counts are correct.

A time out for the count when performing the closing counts would help ensure a correct count. Preventing distractions and interruptions throughout the procedure and ensuring that the entire team focuses on the count process would help ensure that the patient does not leave with a retained item. Surgeon cooperation during the count process would enable the team to count more efficiently.

Institutional policies to encourage taking x-rays of patients who are at high risk for having a retained item could identify most items left behind.12 Electronic tagging of surgical sponges could prevent their accidental retention. This is achieved by tagging sponges with active or inert dummy targets that can be detected by a device that gives off a signal indicating the presence of a retained sponge when it is swept across a surgical site. This type of detection system uses magneto-mechanical technology that is presently used in stores to prevent theft.2 This technology is available but is still very expensive; research is being conducted to investigate ways to help make it more affordable.2

Some companies presently are designing chips (ie, a prototype of the locator chips implanted in animals) for laparotomy sponges and towels.13 Some markers are steel rings that can be attached to items such as towels that do not have a radiographic strip. In addition, many ORs use assistive devices to facilitate correct counts (Figure 2). Useful devices for containing needles are needle-books and magnetic needle boxes. Larger magnetic mats also are extremely helpful to keep track of instruments.

  • View full-size image.
  • Figure 2. 

    Assistive devices, such as a pocketed bag system, help circulating nurses contain items in countable quantities so that the risk of loss or retention in the patient is minimized.

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Everyone's Responsibility 

The numbers of variables that have to be considered during the surgical count process have made errors related to retained foreign bodies too prevalent. It is the direct responsibility of all members of the surgical team to ensure the patient's safety. Team members must use their knowledge of the problems with the count process to be diligent and deliberate during the counting phases of the surgical procedure so no patient has to suffer from a retained item.

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References 

  1. Gawande AA . Risk factors for retained instruments and sponges after surgery . N Engl J Med . 2003;348(3):229–235
  2. Fabian CE . Electronic tagging of surgical sponges to prevent their accidental retention . Surgery . 2005;137(3):298–301
  3. Shea MA , Northcutt C . Making sense of standards of care . In:  Abele JR editors. Medical Errors and Litigation: Investigation and Case Preparation . Tucson, AZ: Lawyers and Judges Publishing Company; 2004;p. 195–196
  4. Pecuniary  . In: Merriam-Webster's Collegiate Dictionary . 11th ed.. Springfield, MA: Merriam-Webster, Inc; 2003;p. 912
  5. Compensatory . In: Merriam-Webster's Collegiate Dictionary . 11th ed.. Springfield, MA: Merriam-Webster, Inc; 2003;p. 253
  6. Punitive damages . In: Merriam-Webster's Collegiate Dictionary . 11th ed.. Springfield, MA: Merriam-Webster, Inc; 2003;p. 1009
  7. Fact sheet on the National Practitioner Data Bank. National Practitioner Data Bank . http://www.npdb-hipdb.hrsa.gov/pubs/fs/Fact_Sheet-National_Practitioner_Data_Bank.pdf Accessed December 29, 2007.
  8. US Department of Health and Human Services. National Practitioner Data Bank (NPDB). Annual Report 2005 . http://www.npdb-hipdb.hrsa.gov/pubs/stats/2005_NPDB_Annual_Report.pdf Accessed December 6, 2007.
  9. Nordenberg T . Make no mistake: medical errors can be deadly serious . FDA Consum . 2000;34(5):13–18
  10. Recommended practices for sponge, sharp, and instrument counts . In: Perioperative Standards and Recommended Practices . Denver, CO: AORN, Inc; 2008;p. 293–302
  11. Girard NJ . The countdown to safety [Editorial] . AORN J . 2004;79(3):575–576
  12. Beyea SC . Counting instruments and sponges [Patient Safety First] . AORN J . 2003;78(2):290–294
  13. Bacheldor B . Surgical sponges get smart. RFID J . http://www.rfidjournal.com/article/articleview/2518/1/1/ July 26, 2006; Accessed December 6, 2007.

  indicates that continuing education contact hours are available for this activity. Earn 3.1 contact hours by reading this article and the following article and taking the examination on pages 329–330 and then completing the answer sheet and learner evaluation on pages 331–332.You also may access these articles online at http://www.aornjournal.org.

PII: S0001-2092(07)00504-2

doi:10.1016/j.aorn.2007.07.023

AORN Journal
Volume 87, Issue 2 , Pages 315-321, February 2008

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