NoThing Left Behind®: A National Surgical Patient Safety Project to Prevent Retained Surgical Items
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Sponge ACCOUNTing System

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

Sponge ACCOUNTING requires the structural elements of a wall-mounted dry erase board in every procedure room or OR and the use of plastic hanging blue-backed sponge holders which can be purchased from any medical distributor. The surgical counts are entered on the dry-erase boards in a standardized format that is the same in every OR or L&D room throughout the suite. This is to minimize communication difficulties during change of shifts or relief breaks since the surgical count information will be transparent and organized in the same way for everyone. OR staff determine the optimal format for each hospital and must reach unanimity on the board formats. Standard issue surgical sponges are used which contain a radiopaque marker and the process is designed primarily for sponges which are used "free", that is passed back and forth without an instrument between the surgical scrub and the surgeon. The process of the surgical count is fully compliant with established AORN recommended practices but there different defined communication strategies and practices in the management of the sponges as they are used. The system involves standardization of practice for surgeons, nurses and surgical technologists, radiologists and radiology technologists in the management and accounting of surgical sponges. The process is transparent, verifiable, inexpensive, relatively uncomplicated and can be used anywhere. The expected outcome is zero cases of retained sponges. 

Download the Policy here and here are some things that you will need:

The three OR signs are essential to the practice and act as memory joggers to help everyone in the OR or L&D room get it right. The three signs are the 1) OR Rack sign that goes on each rack which holds the sponge holders as a visible signal to everyone that all the sponges go in one place at the end of the case 2) the Safety Rules that guide actions throughout the case to prevent correct count retention cases and 3) the Incorrect Count Checklist sign that is available as a checklist for best practices so everyone will know what to do in the setting of an incorrect count. These signs (in pdf format) are available to download and print here: 

1) OR Rack Sign (11" x 11" printout put on fiberboard fits on each sponge holder rack) 

2) OR Safety Rules Sign (8½" x 14" legal size paper) 

3) OR Incorrect Count Checklist Sign (8" x 14" legal size paper).



The plastic hanging blue-backed sponge-holders are mounted on a rack on an IV pole. Each holder (not called a “counter” or a “bag” because the holder “holds” the sponges so they are easily seen by all) contains 5 pouches and each pouch has a thin center-divider which separates each pouch into 2 pockets. Circulating nurses place one sponge in each pocket as outlined. One sponge per pocket, 2 pockets per pouch and 5 pouches per holder means that each holder can accommodate 10 sponges. Each holder is always set up to hold 10 sponges be they laparotomy pads or raytex and different types of sponges are not mixed within one holder. Free sponges are always added to the field in groups of 10. Each rack can usually accommodate 10 sponge holders (5 on each side) which is 100 sponges!


A wall-mounted dry erase board to record operative information and the IN counts should be easily visible in each room. This position of all information on the dry erase boards should be standardized for use throughout all operating rooms on every case that uses sponges. The counts of the sponges as recorded on the dry erase board should be kept as a running total so it is transparent and easy for anyone to understand how many sponges are out at any time. 

The surgeon should perform a methodical wound exam (MWE) during the “pauze for the gauze” at the closing count to make a best effort to get the sponges out so the nurses can move them out of the kick buckets into the holders and account for them. There are guidelines for the MWE and other surgeon best practices. The practice of a “swish or sweep” is insufficient as sponges have been missed with this technique. The MWE occurs at the "pauze for the gauze" which is not a time-out; it's a natural pause point in the operation and is conducted before asking for closing suture.  


The single most important element in the use of the hanging sponge-holders and the sponge ACCOUNTing system is to make sure that the final count is taken when ALL the sponges that have been opened during the case (used and unused) have been placed in the holders. Since sponges are managed only in multiples of ten and each holder has ten pockets at the end of the case there should be "no empty pockets". The surgeon and nurse can then visually verify during the “SHOW ME” step that all sponges have been accounted for and none remain in the patient. This final step of surgical sponge verification fits in well as part of the debriefing in the surgical checklist.

The key for OR culture change is comprehensive training, active learning and sustained followup. Practice change is difficult to accomplish and it takes far longer than most think. So far it has taken 3 years to get large facilities to zero retained sponges. We recommend ORs develop a comprehensive approach to training, apply internal and external auditing of practice and develop internal OR specific near-miss reporting systems with report out to OR patient safety or quality improvement committees to monitor compliance and take action when needed.