Surgical Objects Accidentally Left Inside About 1,500 Patients In US Each Year

About two-thirds of the surgical objects left behind are sponges, which can lead to pain, infection, bowel obstructions, problems in healing, longer hospital stays, additional surgeries and in rare cases, death.

“When there is significant bleeding and a sponge is placed in a patient, it can sometimes look indistinguishable from the tissue around it,” said Dr. Steven DeJong, vice chair, department of surgery, Loyola University Chicago Stritch School of Medicine, Maywood, Ill. “Unintentional retained sponges and instruments is a devastating complication for patients and is a national problem affecting every hospital in the country that performs invasive and surgical procedures.”

To prevent this potentially deadly problem, Loyola University Medical Center is the first center in the Midwest to utilize a new technology that is helping its surgical teams keep track of all sponges used during a surgical procedure. The new system was brought to Loyola through the efforts of the hospital’s operating room nurses.

“This is another safety measure that we’re certain will help us deliver the safest, highest-quality patient care available,” said Dr. Paul K. Whelton, MSc, president & CEO, Loyola University Health System.

This technology is very familiar to anyone who has ever used a grocery checkout system. Each sponge has a unique bar code affixed to it that is scanned by a high-tech device to obtain a count. Before a procedure begins, the identification number of the patient and the badge of the surgical team member maintaining the count are scanned into the counter. As an added safety feature, the bar code is heat sealed into the sponge to eliminate any danger of it becoming detached during a procedure.

The counter has a color screen that keeps a running count of the sponges used. It provides visual and audio cues when a sponge is scanned in, scanned out and if one is missing or is being counted twice. Because each bar code is unique, the system will not allow a sponge to be accidentally counted twice.

“We perform complex cases that we do on a frequent basis that require hundreds of sponges. Sometimes things move very fast, especially when you’re doing an operation for trauma. It’s not too hard to imagine that something might be missed,” said Jo Quetsch, RN, clinical director, surgical services at Loyola.

Quetsch is a member of the surgical nursing leadership team that played a key role in bringing the new system to Loyola.

“This device will help us eliminate the human factor in our standard counting procedure,” Quetsch added. “We are definitely able to keep track of all sponges.”

When a sponge is removed from a patient, it is scanned back into the system. A surgical procedure cannot end until all sponges are accounted for. If a sponge is missing, the device will alert the surgical team what kind of sponge it is and the time it was scanned in. When the count is completed and approved at the end of a procedure, the system can print, archive or download a report as backup documentation and the count.

“This isn’t replacing our standard counting procedures,” Quetsch said. “We will continue to do three hand counts as always – one count when a patient is receiving a sponge, another count when closing begins and a last count at the end of closing.”

The system, which is FDA approved, is being used in all of Loyola’s operating rooms, its labor and delivery rooms, interventional cardiology laboratories in which surgical procedures are performed and its ambulatory surgery sites. As the technology grows, Loyola plans to use it to keep track of all medical equipment used during a procedure.