Patient Safety and Quality

Counting surgical sponges and instruments can prevent some being left in the patient, but better methods are needed

Sponges, needles, or surgical instruments are left in a patient's body once in every 7,000 surgeries (0.014 percent), estimates a new study. Operating room (OR) nurses typically count instruments before and after surgery to identify discrepancies. If an item is missing, OR staff locate it either in the OR or inside the patient before the surgical incision is closed. However, prolonged and complex surgeries that involve staff fatigue, changing teams, and interruptions can interfere with counting accuracy. The study of 153,263 coronary artery bypass graft (CABG) operations found that final count discrepancies identified 77 percent and prevented about half (54 percent) of retained surgical items.

When the final count was discrepant, the odds that a foreign body was inside the patient increased 113-fold. However, given the low incidence of retained foreign body cases, the positive predictive value of this approach was only 1.6 percent. In these cases, clinicians must consider the tradeoff between taking the time to reconcile a count discrepancy (when there is a 98.4 percent chance that there is no foreign body retained), for example, by having the patient wait in the OR for an x-ray, and raising patient risk by delaying closure of the operative site. Also, needles, some of which are undetectable by x-ray, are the items most often lost in the OR. The sequel of further tests and searches started by count discrepancies also raises the cost of the surgery.

Based on this study's discrepancy rate (6.54 percent), the researchers calculated that a count discrepancy increased by $932 the cost for CABG. This would amount to an additional $24 million per year in OR CABG costs. These findings can be used to estimate the benefit of adopting technological alternatives, such as radio-frequency detection systems and bar-coded sponges, over the diagnostic accuracy of counting.

The findings were based on analysis of data from the Medical Event Reporting System-Total HealthSystem, administrative hospital, and the New York State Cardiac Surgery Report databases (2000 to 2004). The study was supported by the Agency for Healthcare Research and Quality (HS11095).

See "Managing the prevention of retained surgical instruments: What is the value of counting?" by Natalia N. Egorova, Ph.D., Alan Moskowitz, M.D., Annetine Gelijns, Ph.D., and others, in the January 2008 Annals of Surgery 247(1), pp. 13-18.

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