Causes of Failure to Prevent Retained Surgical Sponges ID'd

Common causes found to be distraction, multitasking, not following procedure, time pressure

TUESDAY, Aug. 2 (HealthDay News) -- Failure to prevent retained sponges after surgical procedures occurs at different points in the perioperative process and may be due to a wide range of causes, including distraction, multitasking, not following procedure, and time pressure, according to a study published in the August issue of the AORN Journal.

Victoria M. Steelman, Ph.D., R.N., from the Iowa City Veterans Administration Health Care System, and Joseph J. Cullen, M.D., from the Veterans Administration Medical Center in Iowa City, examined perioperative processes that are used to prevent retained sponges after elective abdominal surgery to identify potential failures in surgical counts and the causes, probability, and severity of these failures. A hazard scoring matrix was used to identify failures that should trigger consideration of potential action to control the failure.

The investigators identified 57 cases of potential counting failures, which were mainly attributed to room preparation, initial count, adding and removing sponges, and the first and final closing count. More than half the failures occurred before the closing counts began, and some failures occurred during more than one step of management. A total of 26 causes were identified for these failures, with 106 failure/cause combinations identified. The most frequent causes were distraction, multitasking, not following procedure, and time pressure. Failures that should trigger consideration of action included those occurring in room preparation, the initial count, adding sponges, and removing sponges. The final count received the highest hazard score.

"Surgical counts are failure-prone processes that are not likely to be affected by traditional education and disciplinary interventions," the authors write.

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