BACKGROUND:Surgeons and operating room teams rely upon the
practice of sponge, sharp and instrument counts as a means to
eliminate retained surgical instruments.
BACKGROUND: Counts are also a method of infection control and
inventory control, and a means to prevent injury from contaminated
sharps and instruments.
The PROBLEM: The process by which counts are performed is not
standardized and is often modified according to the individual
hospital policy. Even when present, counts are frequently omitted
or abbreviated in emergency or transvaginal surgeries, or for
RETAINED SPONGES:In cases with retained sponges, sponge counts
had been falsely correct in 76% of non-vaginal surgeries; in 10% of
these cases no sponge count had been performed at all.
RETAINED SPONGES:Falsely correct sponge counts were attributed
to team fatigue, difficult operations, sponges "sticking together,"
or a poor counting system. Incorrect sponge counts that were
accepted prior to closure resulted from either surgeons' dismissing
the incorrect count without re-exploring the wound, or nursing
staff allowing an incorrect count to be accepted.
Retained Surgical SpongesRetained surgical sponges result from
faulty Operating Room practices.
IMPLEMENTING CHANGE:The existing system of sponge and instrument
counts probably works well, but we have no evidence to describe its
actual failure rate. The little existing evidence suggests that it
fails due to human-related factors (i.e., the count not performed,
or is ignored, and that ancillary methods such as x-rays are also
Retained SpongesSponges:Most common retained surgical
item.Detection can be difficult.
CHW History and Goal
FY2008FY2009FY2006FY2010FY2007Small changes in our
practiceSPONGE ACCOUNTING170?1615Number of Retained Sponges
CHMCs CURRENT PRACTICEThe responsibility for preventing retained
sponges has relied on the practice of counting. At the end of the
case we ask What is the count?Error rates with counting are
approximately 10-15%In 80% of retained sponge cases the count has
been falsely called correct.
PROBLEM WITH OUR CURRENT PRACTICE:Having your entire system rely
on only one faulty element is not a very safe system
ALTERNATIVE APPROACHNow we need to ask a different question:
WHERE ARE THE SPONGES?Change the focus away from counting and
towards a system that requires accounting and visible confirmation
PLAN TO PREVENT RETAINED ITEMS:Establish a systematic
process.Every case should have a sponge count performed.
All wounds are at risk--- vaginal deliveries tooRetained sponges
occur with low sponge count cases (20 sponges).
SPONGE ACCOUNTing ROLES IDENTIFIED:Nurses will use a
standardized process to put all sponges in hanging sponge holders
and document the sponge counts on a white board in each Operating
Room.Surgeons will perform a methodical wound exam before closing
in every case and verify with the nurses before leaving the
Operating Room that all the sponges are in the holders.
APPROPRIATE COMMUNICATION: Its what is right not who is
rightBetween nurses and surgeonsWere missing a sponge. Lets
re-explore the wound!I am going to place the used and unused
sponges in the holders now so we can do a Final Count.Between
nursesSeparate each raytex so we can make sure we dont miss
one!Lets verify the sponge holders before we complete Change of
Shift Sign-Off.Between surgeonsMake sure you check behind the
uterus for that raytex I stuck there before you close.Lets do our
wound exam and look for sponges before we close.
Legal RecapPreventing retained sponges is a joint and shared
Sponge ACCOUNTingNew items to help implement the change...
NEW Plastic Hanging Sponge Holders The Hanging Sponge Holders
are now blue-backed to assist in visualization of the sponges
(compared to the previous clear-backed holders).
NEW Plastic Hanging Sponge Holders (continued):Each contain 5
pouches. Each pouch has a thin center-divider which separates each
pouch into 2 pockets. One sponge will be placed in each pocket.
Each holder can accommodate 10 sponges.The sponge holders are held
on racks mounted to IV poles. Each rack can usually accommodate 10
sponge holders (5 on each side) which is 100 sponges!
NEW Clear Plastic Lined Kick Buckets: To aid in the
visualization of bloody sponges in the procedure, the plastic bags
lining the kick buckets will now be changed from red to clear
NEW Dry-Erase Boards in the ORsNew dry erase boards have been
created to help standardize the process in our Operating Rooms.
Sponge Holders In Practice:Guidelines:Use sponge holders for
laps and raytex on all cases that require a sponge count. Use a
separate holder for each sponge type (i.e. one holder for laps
& separate holder for raytex). Used sponges coming from the
operative field should be placed into the CLEAR plastic bag-lined
receptacle (i.e. kick buckets).
Process for Loading the Sponge Holders:Each used sponge will be
taken from the kick bucket receptacle and placed in a pocket on the
Sponge Holder.The folded sponge will be placed in the pocket with
the blue tag or blue stripe visible. This is what differentiates a
sponge with a radiographic marker from a dressing sponge.
Process for Loading the Sponge Holders (continued):The first
sponge will be placed in the LAST pocket in the bottom of the
holder. The Holder will be loaded horizontally from the bottom row
to the top row, filling first the bottom two pockets and continuing
upwards. This process (going from the bottom to the top) will make
visual determination of the filled holder easier to see from the OR
Process for Loading the Sponge Holders (continued):Periodically
throughout the case the used sponges will be placed in the
The NEW Dry-Erase Boards In Practice:New Guidelines:
Now it is a running totalRecorded as: 10102010301040Always in
factors of 10 (sponge packs can only be added in groups of ten
now).Standardized system for all ORs (L&D and Main OR will be
practicing this way).
The NEW Dry-Erase Boards In Practice (continued):When adding a
set of ten laps, the new set is added by setting the ten quantity
set above the current total.
Wound Review: Checks and BalancesThe Methodical Wound Exam
Methodical Wound ExplorationA methodical exploration of the
operative wound must be conducted prior to closure in every
operation. The space to be closed must be carefully examined.
Special focus should be given to closure of a cavity within a
cavity (i.e., heart, major vessel, stomach, bladder, uterus, and
vagina). Surgeons should strive to see and touch during the
exploration whenever possible; reliance on only one element of
sensory perception is insufficient.
MWE RecapThe surgeon should visually and manually make every
effort to assure that no unintended surgical items have been left
in body cavities. The general process is to look and feel in the
recesses of the wound and examine under fatty protuberances and
Steps Behind the Methodical Wound Exam:Unless clinically
contraindicated for a specific patient, a systematic approach
should be used for procedures performed in the abdomen or
Steps Before Removing the Retractors: These steps should be
performed before removing stationary or table mounted
Steps Before Removing the Retractors:Examine all four quadrants
of the abdomen with attention to: Lifting the transverse colon
Checking above/around the liver and above/around the spleen
Examining within and between loops of bowel Inspecting anywhere a
retractor or retractor blades were placed
Steps Before Removing the Retractors:Examine the pelvis Look
behind the bladder, uterus, and around the upper rectum.
Steps Before Removing the Retractors:The vagina should be
examined if it was entered or explored as part of the
Three Phases for Timing the Counts:There will be three standard
times to count in our procedures now:IN CountClosing CountFinal
Three Phases for Timing the Counts: IN COUNT Documentation on
the Dry-Erase board of the initial count of opened itemsOnly X-Ray
detectable sponges or towels can be used.
(Between the Surgical tech and the Circulating Nurse).
Three Phases for Timing the Counts:CLOSING COUNT Pause for the
Gauze The surgeon performs a Methodical Wound Exam while the
circulating nurse performs the Closing Count Call Out I think all
the sponges are out. Then the surgeon can ask for the closing
suture. (Exchange of information between the surgeon and the
Three Phases for Timing the Counts:FINAL COUNT This is the
Verification stepThe surgeon says Show Me and looks at all of the
Sponge Holders. Then the surgeon should dictate in the Post-Op
Report a MWE was performed and all items are ACCOUNTed for.
(Exchange of information between the surgeon and the nurse).
In the Event of a Sponge Miscount:If the surgeon is informed of
a missing object by the circulating nurse, while the OR staff are
looking for the surgical item, the surgeon should stop closing the
wound and repeat the methodical wound examination.
In the Event of a MISCOUNT:On occasion, an incorrect count is
obtained and under these circumstances an intra-operative X-Ray is
required. A written request for a STAT image for foreign body
detection will be generated by the circulating nurse under the name
of the attending surgeon listed in the operation record as being
responsible for the conduct of the operation.
In the Event of a MISCOUNT (continued):Upon receiving the
request, a radiology tech will take an X-Ray of the appropriate
site. The elapsed time should never exceed twenty minutes. The tech
will note time request received and time X-ray taken on the request
slip. The tech taking the X-Ray will call ahead to alert the
radiologist on duty that a wet read is needed from L&D OR.
In the Event of a MISCOUNT (continued):The radiologist on duty
will review the film or the digital images of the X-Ray and will
call the specified OR with the results of their examination or with
a request for additional views to be obtained. The elapsed time
should never be greater than twenty minutes.
Vaginal Delivery Considerations:The Sponge ACCOUNTing process
will also be carried over to our Vaginal deliveries.The vagina is
the open wound for vaginal deliveries.
Vaginal Delivery Considerations (continued):Some small
changes:Now there will be only ten Raytec provided with a Vaginal
Delivery table.There will be a small Dry-Erase board in each
Delivery Suite for the nurse to record the Sponge count.There will
be a clear plastic lined kick bucket in each Delivery Suite.
Vaginal Delivery Considerations (continued):There will be three
counts verified throughout the delivery:IN CountClosing CountFinal
Labor & Delivery LDR Sponge ACCOUNTing
Room #:Date:Visualized/Verified?Patient Initials: Sponges
QuantityIn CountClosing CountFinal Count RaytecLap Sponge
Vaginal Delivery Sponge ACCOUNTing Process:IN COUNT
Documentation on the Dry-Erase board of the initial count of Raytec
(ten included in pack will be the standard).If manufacturer error
found, then the package should be discarded.
(Performed by the Delivery Nurse).
Vaginal Delivery Sponge ACCOUNTing Process:CLOSING COUNT Pause
for the Gauze The Delivery Provider performs a Methodical Wound
Exam of the vagina to search for any remaining sponges.This will be
performed after the delivery of the placenta. Once the count is
verified, the Provider can continue with any laceration/ipis
repair.(Exchange of information between the Provider and the
Vaginal Delivery Sponge ACCOUNTing Process:FINAL COUNT This is
the Verification stepThe Delivery provider says Show Me and looks
at the Sponge Holder. Then in the Delivery Record, the nurse will
document that the Provider and RN verified the count. The Delivery
note by the Provider should reflect that a MWE was performed.
(Exchange of information between the Delivery Provider and the
HOW DO YOU MEASURE SUCCESS?Systematic implementationPatient
centered care - every case, every patient, every timeWorking
together for the patients best interest Goal is ZERO retained
sponges in 10!
Zero Retained Sponges in 2010!The End!