SAFETY IN CERTAINTY Retained surgical items occur regardless of whether the manual counts were correct, affirming the need for a verification process with adjunctive detection technology.

Like counting a deck of cards and getting 53 when there are really 52, most incidents of retained objects occur as a result of a miscount — a count documented as correct when, in fact, it was off. There's no shortage of explanations and excuses for miscounts: distraction, excess noise, time pressures, or trying to remember and count at the same time. Whatever the reason, so-called correct-count retention cases account for about 70% of the 4,500 to 6,000 cases of retained surgical items reported in the United States every year.

The most likely retained item? Seven of 10 times, it's a sponge. It's estimated that 11 patients every day are sutured up with a surgical sponge still inside them. As retained surgical-sponge incidents are often underreported, these statistics are likely low.

Then there are the near misses. A 2007 study from Brigham & Women's Hospital in Boston found that counts are off in 1 of every 8 surgeries. In none of the study cases was an item left in a patient's body, but the rate of faulty surgical counts is alarming.

What's clear from this muddled math is that the manual counting of surgical sponges, sharps and instruments is susceptible to human error and that manual counting alone is insufficient to prevent retained sponges. The Joint Commission, the Association of periOperative Registered Nurses (AORN) and the American College of Surgeons recommend the use of sponge counting and detection technologies to supplement and verify the manual count.

Beyond the whiteboard
No technology can prevent medical mistakes in every situation, but digital safety nets can be an important second line of defense against the risk of retained items.

When Boston Children's Hospital set out to augment its manual count process, OR nurses researched and trialed 2 sponge detection systems: one that uses bar-coded sponges and one in which sponges are imbedded with radiofrequency (RF) tags.

The RF system won out. Boston Children's installed wands and consoles in every OR, and replaced all sponges with RF-tagged sponges. When you pass a wand-like device over the patient, an alarm sounds if it detects the presence of an RF-tagged sponge. Nurses typically perform a scan after the final count and before final closure, but they can wand a patient anytime they're concerned about manual count accuracy. To find a sponge that was unaccounted for, they no longer have to X-ray patients or rummage through the trash. Boston Children's nurses stress that while the RF system is a quick and efficient way to validate correct manual counts and to rectify miscounts, it doesn't replace the hospital's standardized manual counting process.

In addition to sponge detection systems, computerized counting systems verify the manual count and highlight any discrepancy while you can still address it during surgery. Sponge-counting systems use a computer-assisted scanner that records a unique barcode embedded in each sponge and towel to provide a precise, real-time count. Barcode scanners require a direct line of sight, so you must manually scan items in and out. It's not a detection system, so it won't locate missing sponges and gauze to rectify a miscount or address the risk of a retained surgical item when the count otherwise appears to be accurate. At the end of a case, the system generates an electronic report of the count.

SPONGE ACCOUNTING Line kick buckets and sponge receptacles with clear plastic bags instead of red or white ones so staff can easily see bloody used sponges and unused sponges.

The psychology of counting
How do so many correct counts turn out to be incorrect? One explanation is that our brains get crossed up when we try to count and remember at the same time. Studies show that when our brains switch between counting and remembering, we transpose numbers and make transcription errors. Rather than simultaneously summoning the powers of memory and enumeration, you should record one count — on a standardized template in a location that's visible to the surgical team — before starting the next. That's just one of the many lessons AORN gleaned from psychological studies on counting that helped shape its updated Guideline for Prevention of Retained Surgical Items (osmag.net/KRkGa4), says Amber Wood, MSN, RN, CNOR, CIC, FAPIC, senior perioperative practice specialist with AORN.

Studies have also shown that you can't count accurately beyond 2 when you're distracted. If you're interrupted during a count, don't resume counting but rather start over from zero, says Ms. Wood. Also, don't start counting during critical phases of the procedure, including the time out. Take care of patient care needs before you start the count. Once the patient enters the room, you have an immediate distraction and the patient needs 100% of your attention, so it's better to do the initial count in the relatively quiet few minutes before the patient enters the room. If the baseline count's not accurate, none of the others will be accurate, says Ms. Wood.

Minimizing distractions during initial and closing counts is one of the best ways to prevent retained items, says Mary C. Fearon, MSN, RN, CNOR, a perioperative practice specialist for AORN. 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. 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.

Finally, it's also a good idea to line kick buckets and sponge receptacles with clear plastic bags. Red biohazard bags make it difficult to see bloody used sponges, and white bags make it difficult to see unused sponges, says Verna C. Gibbs, MD, the director of NoThing Left Behind, a staff surgeon at the San Francisco VA Medical Center and a clinical professor of surgery at the University of California, San Francisco. OSM