A1: PROBLEM OR ISSUE
The problem is a retained sponge even after a count was performed and reported correct
in the operating room.
A1A: EXPLANATION OF PROBLEM OR ISSUE
I am a registered nurse in the operating room at a local hospital in Greensboro, NC. In
one of our facilities a sponge was left in a patient even after a count was performed and reported
as a correct count. There is a policy in place regarding counting items used during surgery.
Having a policy is important for patient safety. Leaving an unintended item in a patient can have
a devastating effect on a patient and their family. It can lead to infection, pain, and even death.
It can also be difficult for the institution. Patients can lose trust in the hospital and staff. There
can be lawsuits and penalties associated with retained items.
A2: INVESTIGATION
“Studies have shown that one in fifty-five hundred surgeries results in a retained surgical
item mainly being a surgical sponge.” (Williams, 2014) My specific health system has had a
retained sponge even after a count was performed by two people and reporting it was correct. I
have spoken to several staff members and they all agree that errors can happen. After reviewing
our current policy regarding counting it was agreed upon that we need to have a safety net that
can catch those errors. Leaving a sponge in a patient can hurt the patient and the facility.
Having a safeguard is beneficial for all parties involved.
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