Nothing Left Behind®: A National Surgical Patient Safety Project to Prevent Retained Surgical Items
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Prevention of Retained Soft Goods: Sponges and Towels


Zooming in on Zero Retained Surgical Sponges

The prevention of retained surgical sponges requires good communication among perioperative personnel and the consistent application of standardized processes of care. Review of individual cases, focused reviews and root cause analyses from multiple sources have revealed that operating rooms run into trouble in compliance with the “consistent application” and with the development of “standardized” processes of care applicable to all stakeholders. 

Most hospitals have a surgical count policy which directs behavior of the staff nurses and surgical technologists yet have no policies which direct behavior of surgeons, anesthesiologists and radiologists – other important perioperative personnel. Additionally the practices outlined within existing count policies are often not standardized and uniformly practiced throughout all the operating rooms even though they comply with the recommended practices of the AORN. It is often the case that everybody has "my" way of doing things but there is no standardized way. This state of affairs allows for much individual and service-specific variation. A 2018 MultiStakeholder Prevention of Retained Surgical Items Policy job aid/reference manual has been newly revised and is available here.

Here is a video on the Sponge ACCOUNTing System to see how it works

The most common retained surgical item that requires a second operation to remove, is a surgical cotton gauze sponge, used during the course of an operation to soak up body fluids or help maintain the surgical field. All surgical sponges used in the US contain a radiopaque marker which distinguishes them fromcotton gauze dressings which don't contain markers and are used to cover the wound. The three main “stakeholders” in preventing retained sponges are surgeons, nurses and radiologists and communication between all three is a key element and having safe practices. The doctor has to perform a methodical wound exam, the nurse has to have a reliable sponge management practice and radiologists and radiology technologists have to take high quality x-rays and provide image interpretation. Surgeons and Nurses are the primary defenders against retention and Radiologists are secondary defenders that mitigate harm. Even if new technology adjuncts are employed there is still a very important role for Radiologists to remain team members and help find missing surgical items. There should be an alliance between the surgeon - whose responsibility it is to remove all surgical items not intended to remain, and the surgical nurses - who are responsible for corroborating or refuting the surgeons assessment that everything has been removed. Preventing retention is a joint and shared responsibility.

Transparency in practice is important and hard to deliver in the OR when everyone is scrubbed and sterile. Having a communication tool that helps everyone know safe practices to find a missing sponge or surgical item can start everyone out on the right track. No need to rely on memory or past experience if information is right on the wall. Here is a poster that prints on legal size paper which we call the INCORRECT COUNT CHECKLIST to be placed on a wall in each OR so all stakeholders can see what best practices are and what they have to do when an item is missing. 

                  NCRC        CCRC ICRC

These are cases of retained sponges where by policy or established practice (not error) no surgical counts were performed. These circumstances most commonly have occurred in cardiology suites where pacemakers have been inserted, radiology areas where infusion ports are placed and surprisingly this state of affairs is very common in perinatal birthing rooms. Not the C-sxn operating rooms, but the birthing rooms where vaginal births take place. In addition, surgical sponges have not been the standard but the use of non-radiopaque dressing sponges is more commonly observed. The first x-ray is from a case of a retained vaginal sponge that was discovered after the mother went to an emergency room with pelvic pain and a foul discharge. This shows that it is important to use radiopaque sponges during a birth, so if there was a postpartum problem from a retained vaginal sponge the sponge could be detected by x-ray. These cases present new challenges to L&D and medical personnel to adopt and learn a safe sponge management practice. They also have to learn correct methods of the use of surgical sponges so if one if left behind at least there is a means to detect it's presence. These cases account for about 5% of retained sponge cases.


To date, most OR’s have placed undue reliance on the surgical count to the exclusion of other actions to prevent unintentional retention. Error rates with current manual counting practices are ~10-15% and in over 80% of retained sponge cases the count has been falsely called "correct". We characterize these cases as correct count retention cases. That is, the sponges were counted but there was an error(s), such that at the end of the case the counts were called "correct" but a sponge was still in the patient. In the middle x-ray, the patient had a lung operation and during the case lap pads were used. The sponge count was called "correct" at the end of the case and a "sweep" had been performed before closing the chest. On a routine postop chest x-ray there is the marker of a retained lap pad discovered by the radiologist on image review. In these CCRC the retained sponge is usually discovered hours, days, months or years later and are always a surprise. These cases are the result of problems with the practice of counting. Manual counting practices are tried and true but they are not standardized and as currently practiced in most ORs they are not conducted in a way that there is a transparent way to discover when error occurs or visible verification process.


In 15% of retained sponge cases the patient has left the OR with a known incorrect count. That is, it was known that something was missing but the item was never found. It is difficult for people to understand how these cases occur. If it was known something was missing, how did the patient get out of the OR with the sponge still inside of them? These cases are usually the result of problems with communication and knowledge. The sponge management practice worked because the team knows there is a missing sponge but the actions taken to find the sponge are incomplete or inadequate. Problems with communication between surgeons and nurses, misinterpretation of xrays, incomplete xray examinations, and insufficient wound examinations often reflect a lack of knowledge about what is the best course of action under the circumstances. In the third x-ray there is a drain in the pelvis and a ureteral stent and when the nurses identified that a lap pad was missing, the surgeon read the x-ray and missed the lap pad marker and this hospital didn't have radiologists reading back directly to the OR so there was no "content expert" reading the images. The lap pad was discovered when the radiologists reviewed the images the next day, but the patient was already out of the OR by then.

The point here is that all RSI cases are not the same and just knowing there was a retained sponge is not enough. It's a better start towards working on solutions if we know what "type" of retention case it was. NCRC and CCRC are cases that have primarily practice problems and ICRC have primarily communication problems. If there is no practice or an unreliable practice then that's where the work is. If there is poor communication in a ICRC, then strong communication tools and strategies need to be developed.

We suggest that we have been asking the wrong question: Instead of saying What's the count? - we should be asking Where are the sponges? To answer this question, we have designed and studied a sponge management practice called the Sponge ACCOUNTing System which is a transparent, systemized, standardized, inexpensive, simple manual practice to account for surgical sponges. The system requires the use of blue-backed plastic hanging sponge holders as a adjunct to the performance of surgical counts and has visible verification steps that provide greater certainty about the number of sponges used during a case and proves that those sponges are all in one place at the end of the case. There are practice handouts for the three stakeholders which define standardized practices and communication tools to help the humans work together in the management of the surgical sponges. 
These materials are available under the Sponge ACCOUNTing tab here on the website.

If there have been cases of retained sponges with your current OR manual practice and your organization is interested in working with their current investment in OR personnel without adding new technology, this Sponge ACCOUNTing system should be evaluated. If your organization is interested in looking at the new technological adjuncts to sponge counting, the two commercially available devices are briefly discussed. The systems are not interchangeable and have their separate strengths and weaknesses. It turns out that there is not one best practice since all of these systems must be used in the local environment of each hospital. The cultures and level of complexity of hospitals are important determinants of which approach will be successful in RSI prevention. 

The goal of this project has been to help hospitals get to zero retained sponges for at least one year to eliminate the problem of retained surgical sponges in all ORs, labor and delivery rooms and radiology suites….. any place that surgical sponges are used and an incision is made, which are the minimal conditions for the possibility that a sponge can be left in a patient. The goal is zero which means that all members of the perioperative care team must work together to insure that no patient leaves the OR with a surgical sponge unknowingly left inside of them, no new mother goes home with a vaginal sponge inside of her and no radiologist misses a radiographic sponge on an xray.

Blue, green or natural (unbleached) OR towels are manufactured to a standard to be used as surgical drapes. They are usually of a coarser grade of cotton and contain dyes and are not intended to be placed inside of wounds. Some surgeons use these towels for viscera retraction but because they are considered part of the surgical drapes these items are not counted. These drape towels do not contain radiopaque markers.  Retained towels have been mistaken for masses or have caused intracavitary abscesses. If towels are going to be placed inside of patients then white cotton towels with radiopaque markers should be purchased (surgical towels) and when they are added to the field they should be tracked on the dry erase board just like the other white cotton sponges. These surgical towels should not be used as drapes because if there is a need for an intaoperative xray the radiopaque markers may obscure the radiographic view. If surgical towels are on the field they should be removed before taking the image. In the 2018 NoThing Left Behind Policy there is a section on the management of OR towels. Here is a pdf of the towel management protocol from the policy.