Abstract:
:A retained surgical sponge is a sentinel event that can result in serious negative outcomes for the patient. Current standards rely on manual counting, the accuracy of which may be suspect, yet little is known about why counting fails to prevent retained sponges. The objectives of this project were to describe perioperative processes to prevent retained sponges after elective abdominal surgery; to identify potential failures; and to rate the causes, probability, and severity of these failures. A total of 57 potential failures were identified, associated with room preparation, the initial count, adding sponges, removing sponges, the first closing count, and the final closing count. The most frequently identified causes of failures included distraction, multitasking, not following procedure, and time pressure. Most of the failures are not likely to be affected by an educational intervention, so additional technological controls should be considered in efforts to improve safety.
journal_name
AORN Jjournal_title
AORN journalauthors
Steelman VM,Cullen JJdoi
10.1016/j.aorn.2010.09.034subject
Has Abstractpub_date
2011-08-01 00:00:00pages
132-41issue
2eissn
0001-2092issn
1878-0369pii
S0001-2092(11)00615-6journal_volume
94pub_type
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