Counting matters: lessons from the root cause analysis of a retained surgical item

Retained surgical items (RSIs), such as a sponge, instrument, or needle, after a surgery or invasive procedure is an uncommon but potentially serious event associated with significant morbidity and mortality. A 27-year-old woman was discovered to have a retained vaginal sponge a week after she underwent the repair of a vaginal tear following normal vaginal delivery. The retained sponge was removed with no further complications.

The fundamental error involved the obstetric team's failure to perform the standard protocol of counting sponges before, as well as after, the procedure. This was attributed to a lack of reminders to perform the count, relatively recent implementation of the sponge-count policy, and a breakdown in teamwork and communication between physicians and nurses.

The corrective actions focused on systems improvement, as opposed to the human error of the memory lapse. The sponge-counting process was reinforced by incorporating a sign-out at the end of obstetric procedures to ensure that the counts have been done and any discrepancies addressed. A specialized delivery note with mandatory field to document sponge count was implemented in the electronic health record as an additional reminder. All staff participated in a teamwork and communication training program.

Since the incident's occurrence in 2010, the staff has demonstrated 100% compliance with the corrective actions, and a retained surgical item complication has not recurred.

Individual accountability must be balanced with systems improvement, given that most medical errors are a result of fallible humans working in chaotic, unpredictable, and complex clinical environment.