November 1, 2009
Preventing retained surgical item: What role does technology play?
A patient needs major surgery to remove 5 laparotomy sponges left behind during a previous case. The investigation finds that during an exploratory laparotomy, the circulating nurse introduced a 5-pack of sponges into the sterile field but did not enter the count on the worksheet or white board. Relief staff were not aware of the extra 5 sponges, and the count later appeared correct. The incident is 1 of 6 retained-item cases that resulted in $25,000 fines for California hospitals in September 2009.
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