Every year 4,500 to 6,000 patients have retained surgical foreign objects unintentionally left in their bodies following surgical procedures. The majority of those objects are retained surgical sponges (RSS), typically the result of human error in the operating room.
Leaving a sponge behind in a patient is considered a “never event” — a medical error that should never happen. That’s according to The Joint Commission, a nonprofit committed to quality improvement and patient safety in healthcare.
“It’s a big deal,” says Valerie Y. Marsh, DNP, RN, CNOR, who’s been an operating room nurse for over 35 years. “More so now than ever, just because we’re looking at good quality for our patients and keeping them safe.”
Keeping count
According to a medical study of 319 occurrences of retained surgical sponges from 2012 to 2017, over 50 percent of sponges were retained in the abdomen or pelvis and nearly 24 percent were in the vagina. Almost 70 percent of the cases had unexpected additional care or extended stay, while nearly 15 percent had severe temporary harm. One patient died as a result of a retained sponge.
“If there’s a miscount in sponges, sometimes they’ll take the patient right back to the operating room from the post-procedure area,” says Marsh, noting a patient may need to be x-rayed to see if the sponge was left inside. “Other times, the patient might start to exhibit symptoms after a few days, like infection or abdominal pain.”
In the OR, nurses and doctors count and track the sponges used during a procedure. Radio frequency devices can detect how many sponges have been used but that technology is not always accurate.
Newer technology, the SurgiCount Safety-Sponge System, is designed to reduce the risk of leaving a surgical sponge inside a patient. Each sponge has a unique barcode for 100 percent identification accuracy. The system operates on a scan-in/scan-out process, accounting for every sponge used during surgery.
Marsh, a consultant for Stryker, the medical technology company that makes SurgiCount, compares it to scanning food at the grocery store.
“The SurgiCount will say, ‘this is sponge number 12. This is sponge number 13,’” she says. “It scans them in and it gives you the numbers, and when you scan them out, it gives you the numbers. It matches sponge to sponge before and after surgery.”
Stryker says this product has been used for over 11 million procedures across the country without any retained items.
The Association of Operating Room Nurses advises counting the sponges five times — manually and with technology — before, during, and after surgery. Marsh agrees and says doing both is “double protection.”
SurgiCount’s user-friendly tablet interface has expanded capabilities, including WiFi capability with real-tile data transfer, secure cloud-based server/storage, and an admin portal for password protected, VPN access from any computer, onsite or remote.
Risk-sharing
By investing in this technology, providers and facilities can avoid the “never event” of RSS, which protects patients, providers, and facilities. The American Society of Anesthesiologists reports RSS malpractice suits cost over $150,000 per case.
“The cost analysis of bringing in this product versus litigation and the emotional stress of the litigation is going to be a huge benefit to the institution,” says Marsh.
Stryker has a risk-sharing program, where the company agrees to provide up to $5 million to cover legal costs if a sponge is inadvertently left in a patient. They also agree to refund incremental costs necessary for up to three years for hospitals to implement the SurgiCount system over a prior sponge system.
Marsh says this technology helps providers ensure they’re consistently tracking surgical sponges.
“It’s important to have a standard process and standard policy, and following the work and not varying from your practice,” says Marsh. “Do it the same way every single time and you won’t make a mistake.”