Sponges, surgical instruments miscounted in 13% of surgeries

Getting the count right in the operating room is a challenge. New technologies could make things easier.

By Kevin B. O’Reilly — Posted Sept. 22, 2008

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To avoid leaving sponges or surgical instruments inside a patient after surgery, nurses count these items when a procedure begins and ends. While cases of retained foreign objects are rare -- occurring once in every 5,000 surgeries -- discrepancies in counts happen in 13% of surgeries, according to an August Annals of Surgery study.

Cases of retained surgical items are classified as a seriously reportable event, or "never event," by the National Quality Forum. The mistake is one of the hospital-acquired conditions that the Centers for Medicare & Medicaid Services will stop paying for as a complicating condition in October. Some health plans also have said they will stop paying for this and other events deemed to be preventable, and many hospitals have pledged to stop billing for the errors.

In the Annals study, researchers observed 148 elective general surgery operations and found that most discrepancies happen when nurses or surgical technologists misplace items in the operating room, usually sponges. Counting discrepancies take an average of 13 minutes to resolve.

"For the number of sponges and instruments that need to be tracked during complex cases, it's beyond what we should expect human beings to be able to do," said Caprice C. Greenberg, MD, MPH, the study's lead author and a surgical oncologist at Brigham and Women's Hospital in Boston.

"We know there's inevitable human error there."

Technology seen as offering a solution

Dr. Greenberg and other patient safety experts say technology can help.

The Mayo Clinic in Rochester, Minn., is switching to bar-coded surgical sponges, which are scanned in and out. The sponges and the bar-coding machine cost about $9 per surgical case. An earlier randomized-controlled trial by Dr. Greenberg and her colleagues found that the bar-coded sponges improved detection of count discrepancies.

A new, more expensive option is a radio-frequency identification system sold by Pittsburgh-based ClearCount Medical Solutions. Dime-sized RFID tags are embedded in the sponges, which can be tossed in a bundle into an accompanying receptacle that counts them. A reusable wand can detect unaccounted-for sponges inside the patient or around the OR. Using this system costs $25 to $45 more per surgical procedure than traditional sponges.

Verna C. Gibbs, MD, said the technologies, while promising, cannot make up for the lack of standardized processes to account for surgical items. "Across the country, there is no gold-standard protocol," said Dr. Gibbs, director of NoThing Left Behind, a surgical safety project. "These technology adjuncts are being overlaid on no standardization to begin with."

Dr. Greenberg and her colleagues plan to present a paper on the cost effectiveness of different sponge-counting and detection technologies at the American College of Surgeons' annual clinical meeting in October.

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External links

"The Frequency and Significance of Discrepancies in the Surgical Count," abstract, Annals of Surgery, August (link)

NoThing Left Behind: A Surgical Safety Project to Prevent Retained Surgical Items (link)

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