Safety Spotlight: none in a million

The numbers are difficult to track, but across the U.S., somewhere around one in every 5,000 to 50,000 surgical patients leaves the operating room with a surgical sponge — used in almost every surgery — accidentally left in their body. On October 14, the surgical teams in our care sites in Utah and Idaho hit 1 million consecutive surgeries without a retained surgical sponge.?

Surgical teams use a lot of sponges to absorb fluids and control bleeding. In a transplant operation, for example, a team might go through 100 sponges — and every one of them needs to be accounted for. It’s easier said than done. Sponges accidentally left in the body can cause severe inflammation and infection — in severe cases, even death.?

In 2016, Intermountain Health launched a concerted effort to eradicate retained surgical sponges. At the time, organizational data revealed an average of one retained sponge every 72 days, about five a year, consistent with known national averages.?

“Many organizations do not track how often these events happen in their hospitals,” said David Kay, clinical operations director of surgical services. “But that data is so important because it informs our teams how they are doing and, more importantly, how they can improve to keep patients safe.”?

Back then, surgical technologists and nurses oversaw a manual sponge count at the end of each case. The new process added a bar code to every sponge: each one needed to be scanned in and out. Initially, that change added time, but those few extra seconds made a significant difference.?

The surgical teams saw the benefit and embraced the change.?

“The technology of a sponge counting system, plus strong policies like obtaining an x-ray for incorrect counts, create a culture of accountability that has been key to retained sponge prevention,” said Mary Anne Douglas, assistant vice president, nursing practice excellence, surgical services.??

“The technology has helped us identify when there is a missing sponge,” she said. “Our teams and surgeons have followed through to get an x-ray while still in the operating room — even when they thought the sponge was not inside the patient. More than once they were surprised to discover the sponge was indeed there and were able to remove it before they closed the skin.” ??

The process of scanning, and the best practices that come with it, have kept every patient since July 28, 2017, from leaving the operating room with a retained sponge — one million consecutive surgeries and counting.?

The process looks a little different now. Sponges are tracked with an RFID chip instead of a bar code. Integration is still ongoing in the Peaks Region, which joined Intermountain after the process was implemented.??

After all this time, one thing is clear:?an accurate count depends on the people who implement it.?

“You have to have the whole team involved,” said Aimee Marshall, clinical high reliability manager with Patient Safety. “It can’t just be the scrub tech counting with the nurse. It’s got to be the scrub tech, the nurse, the anesthesiologist, the surgeon. Everyone.”?

Robert Glasgow, MD, senior medical director, surgical services, Utah and Idaho, agreed.??

“We’ve been proud of our teams in near-miss situations where counts were off, and everybody was willing to pause and make sure the sponge was not in the patient,” he said. “When a team member raises a concern where patient safety is at risk, our teams stop and resolve. That’s how we reached 1 million surgeries with zero retained sponges.”?