Reduce Risk of Retained Surgical Sponges

“I didn’t want to wait until we had a retained item to implement a new system. I didn’t want it to be an after-the-fact correction. I wanted it to be something put in place as a prevention.”

An unintentionally retained foreign object (URFO) was among the top three most frequently reported sentinel events in the U.S. in 2021, according to the Joint Commission. Seventy percent of retained items were surgical sponges and 90% of retained surgical sponge cases had a “false correct” count.

While these events are rare, they can cause varying degrees of physical and emotional harm. A retained surgical item can result in permanent injury or even death to a patient and significant cost for the healthcare organization, as well as have a long-term negative impact on the staff involved in the procedure.

Studies show that the risk of URFOs is significantly reduced following improvements to counting procedures. By enforcing a standardized multidisciplinary count process, healthcare organizations can develop and sustain reliable practices that ensure all surgical items are accounted for and reconciled.

Summa Health has long had a Surgical Services Prevention of Retained Surgical Items policy, in which states that it is the responsibility of the registered nurse (RN) circulator, scrub person and surgical team to track and record items used during a surgical procedure. However, while the Summa Health surgical staff is diligent about following policy and ensuring no items are retained in our patients, failures can still occur. Sponges and swabs can be retained even when a documented count has been performed.

“Since Summa Health wasn’t having an issue with retained items, it was initially a difficult sell,” explains technology advocate Kelly Glendon MBA, BSN, RN, CNOR, Unit Director, Operating Room. “But, I didn’t want to wait until we had a retained item to implement a new system. I didn’t want it to be an after-the-fact correction. I wanted it to be something put in place as a prevention.” With this in mind, the Summa Health operating room’s unit-based clinical practice council recommended the implementation of safety-sponge technology to help ensure that no soft goods (ex. sponges, gauze or towels) are missed and retained during any Summa Health surgical procedure.

While there were some initial challenges to overcome, such as concerns over the significant system cost and possible disruption to the current workflow and efficiencies, Summa Health Surgical Services and Obstetrics Departments went live with the Stryker SurgiCount™ Safety-Sponge System beginning in July of 2021.

The SurgiCount system centers around three products: a comprehensive line of uniquely identifiable surgical sponges and towels (Safety-Sponges™), touchscreen scanning devices (SurgiCounters™), and a networked database application that allows for the review, management, and analysis of the count reports generated. Safety-Sponges are surgical sponges and towels that have a unique data matrix symbology tag tempered to the gauze. These tags are non-absorbent and latex-free polymer strips that repel blood and bodily fluids and display a serial number embedded in a bar code. All Safety-Sponges used in a procedure are scanned with the SurgiCounters before the case, as well as scanned out after the case to establish that the count is correct.

An intuitive, user-friendly tablet technology, the SurgiCount system is used on all of Summa Health’s surgical cases in the operating room (OR) and obstetrics (OB), as well as vaginal deliveries requiring a sponge count. Sponges are counted manually and electronically by the RN circulator and scrub person. The addition of the technology helps staff identify any deviation from best practice and allows for coaching and intervention when needed.

“There was a learning curve, but the staff understood and valued the need for the new system. While they have not been involved with a retaining sponge incident, at least while at Summa, they understand what impact it would have,” explains Glendon. “I was overall pleasantly surprised with the implementation and acceptance of the new technology into our workflow.”

Summa Health Surgical Services has been so pleased with the SurgiCount system that it is adding an upgrade – a wireless reader, or wand, for scanning, counting and finding sponges in the operating room. The additional component is expected at the end of 2022.

“There have been a few instances since we went live that, I think, may have resulted in a retained item if we would not have had this technology,” says Glendon. ”These instances have made the staff thankful for this adjunct technology. think it’s solidified the rationale that we really needed this additional support.”