Leaving a sponge in a patient is a so-called “never event” to safety-assurance agencies and an almost certain way to precipitate a malpractice case.

Current protocols require frequent counts and recounts. As a result, incidents of retained surgical instruments (RSI) are rare, occurring in about one of 5,000 procedures. But all that counting and recounting also raises the likelihood of discrepancies between tallies. A recent Harvard study published in Annals of Surgery (2008;248:337-341) pegs that rate at about one in eight cases.

“The surgical counts are time-consuming and prone to inconsistencies,” says lead author Caprice C. Greenberg, MD, MPH, a surgical oncologist at Brigham and Women’s Hospital in Boston. “Despite this, they still detect many important discrepancies.”

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Most inconsistencies (59%) involved sponges and instruments that could not be immediately located. The rest resulted from miscounts, addition errors, or mistakes in documentation. Every incident was reconciled before the patient left the operating room, but each represented a potential RSI — and lawsuit.

The results demonstrate that “discrepancies should never be dismissed as human error but rather universally prompt a thorough search and reconciliation process,” the researchers wrote. If reconciliation fails, the patient should be x-rayed immediately to ensure unaccounted-for items are not hiding in the body cavity.

The researchers looked at 148 elective operations in general surgery, ranging from outpatient hernias to Whipple procedures and liver resections. These procedures required keeping track of as many as 125 sponges and gave rise to a total of 2,476 counting episodes.

Not surprisingly, sponges accounted for the most misplaced items (45%), followed by instruments (34%) and needles (21%). The counts were frequent, with a mean 16.6 tallies per case, and took about 8.6 minutes per procedure.

The study also found that counts during hand-offs and staff changes were particularly vulnerable. Discrepancies are three times more likely if the surgical technologist or circulating registered nurse changed during an operation.

Focusing on manual count, the study involved patients in the control arm of a trial that compared a bar-coded sponge system with the traditional counting protocol. It was financed with a grant from SurgiCount Medical, Temecula, Calif., which makes the bar-code system

A third part of the project, which analyzes the cost-effectiveness of various sponge-counting technologies was presented at the American College of Surgeons annual clinical meeting in October

“Technological adjuncts and improved hand-off practices have the potential to decrease RSI and improve patient safety overall,” the investigators concluded. “In the meantime, any discrepancy in the count should be interpreted as a potential RSI and never dismissed without reconciliation.”