Retained Sponges Persist as a Surgical Complication Despite Manual Counts

September 26, 2018 | Evaluations & Guidance


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  1. Surgical sponges and other soft goods that are unintentionally left inside the patient after the surgical site is closed can lead to infections and other serious complications, including the need for additional surgery.

  2. Manual counting protocols are standard practice for reducing the risk that any surgical soft goods (e.g., sponges, textiles, and towels, referred to collectively as "sponges") will be retained within the patient. However, manual counts—whereby the surgical team verifies that all sponges are accounted for before concluding the procedure—are prone to error.

a) Staff may miscount the number of sponges—concluding, for example, that all sponges have been accounted for when in fact a sponge is missing (i.e., a false correct count). In this case, the surgical team might not learn of the discrepancy unless or until the patient returns with a complaint of pain or discomfort. Several studies have found that in the vast majority (up to 88%) of cases in which an unintentionally retained sponge...

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