FULL COUNT Retained objects should never happen, but prevention requires time and attention.

What does it feel like to be connected to a case that results in a retained surgical item? It can rock a nurse to the core. A couple of years ago, I sent an email to about 150 surgical nurses in my hospital. I said, If you've ever been involved in a retained-item event and are willing to talk about it, I'd like to hear from you.

More than 20 nurses came forward with stories, many based on experiences elsewhere. The words they used were heartbreaking. Even if the event had nothing to do with them — if a patient had just shown up to have an object removed — they felt grief and despair.

Several cried as they re-lived the experiences. One nurse said she'd seriously thought about leaving the profession. Most said the experience had strengthened their resolve to be better nurses.

It was eye-opening. You can talk and talk about preventing retained items, but the stories they told humanized the issue, and that made other nurses sit up and listen more intently. I know what it's like to be in a busy operating room, and I know that retained objects are completely preventable if we take our time and count correctly. The key is to always stop and pay full attention at that point of the surgery. Otherwise, anyone can make a mistake. And when mistakes happen, they're devastating.

Widespread pain
The first victim of a retained-item event, obviously, is the patient, but nurses and other providers can also be traumatized. They become what's referred to in the literature as "second victims."

I saw the intense emotion in the faces of the nurses who'd seen these events, and heard it in their words — "gutted," "wrecked," "shame," "horrified" and "failure." They were devastated, and they were knocked back on their heels.

REAL CONSEQUENCES
A Life Interrupted by Left-Behind Sponge

CHANGE OF PLANS The Baileys intended to see the country on horseback during their golden years.

Nelson Bailey and his wife, Carol, used to vacation on horseback every year. They'd ride between the coasts of Florida, all the way from the Gulf of Mexico to the Atlantic Ocean. "We did that for 18 years in a row," says Mr. Bailey, a retired judge from Palm Beach County, Fla.

A stray surgical sponge broke the streak.

The sponge, used during a follow-up surgery stemming from a bout of diverticulitis, stayed inside Mr. Bailey for 6 months, wreaking havoc on his intestines. "It pretty well knocked me out of the saddle," he says. "It changed our lifestyle, and not for the better."

Mr. Bailey, now 74, was actually more fortunate than many victims. "I'm leading a reasonably normal life," he says.

But there was nothing normal about the agony he endured as a result of the 12-inch by 12-inch sponge that was left behind after his 2009 procedure.

"I kept going downhill afterward," he says. "In court, everyone thought I was dying. I was losing weight and my health was collapsing. People I hadn't seen for several months would say, Oh my God, what's going on, Bailey?"

He had several X-rays, but the hospital radiologists and his surgeon kept missing the obvious evidence, he says. Eventually, he got a call from his primary care physician, who told him there was a sponge somewhere in his abdomen.

A half hour later, says Mr. Bailey, his surgeon called, offering to take it out for free. "My immediate response was, I'm sure you can understand that I don't have enough faith in you anymore to do that."

Instead, Mr. Bailey went to the Cleveland Clinic Florida in Weston, Fla., where surgeons discovered portions of the sponge balled up between and wrapped around his intestines.

Mr. Bailey sued, and it wasn't until after a confidential settlement was reached that he finally got an explanation — and an apology. He was told that a nurse who was involved in the count had gotten a call in the OR and was told that her mother had been involved in a car accident. "She walked out of the room," he says. "The count is supposed to stop when that happens, but that wasn't done."

Now, the long trail rides he loved are no longer an option. "We were going to see the country on horseback when I retired," he says.

Mr. Bailey's faith in hospitals and the medical profession as a whole has been shaken, he admits, but he refuses to be consumed by anger.

"I knew right away if I got bitter, it would destroy me, emotionally, mentally, in every respect," he says. "I just decided to go on with life as best I could, hand the case over to a good lawyer, and say whatever happens, happens."

What he'd like now, he says, is for surgical professionals to take whatever steps are necessary to make sure it doesn't happen again, to anyone.

— Jim Burger

Some even became sympathetic second victims. One nurse said she'd assisted in a surgery in which it wasn't entirely clear what was wrong with the patient. When they found and removed a retained lap sponge from a previous surgery at another facility, it was devastating, she said. She actually felt deeply for the nurse who'd been involved in the original case.

Surgeons can also be second victims, and one of ours became an important champion in our effort. He shared how he felt when a retained item happened to him, and what it was like to have to tell the patient. He also explained how much he depends on nurses to be the voice, to count correctly and to let him know if anything is missing. And he took responsibility for the role he plays in sweeping the wound at the end of the case. He's a part of the process, he said, not just a bystander.

Never again
Empathy is powerful. In the 3 years since I completed this exercise, nurses here have really taken the issue to heart. It's been several years since we've had an incident, and I expect our success to continue. None of us wants a patient to be a victim, nor do we want to be victims ourselves.

The nurses who'd been through a retained item event said the experience made them extra cautious about taking the time needed to do it right. They also felt compelled to encourage the people around them to pay stricter attention. They felt more empowered to speak up and demand complete focus while the counting happened. Those are important messages for you and your staff to hear. OSM