Retained surgical sponges, needles and instruments.

COMMENT ON Hariharan D, Lobo DN. Retained surgical sponges, needles and instruments. Ann R Coll Surg Engl 2013; 95: 87–92 doi 10.1308/003588413X13511609957218 I read with interest the review by Hariharan and Lobo in which they discuss the incidence of retained surgical items and the seriousness of outcomes to patients, particularly when sponges are retained. Clearly, this issue has not been resolved and requires attention. The authors rightfully point out that the surgical count, a primary preventive measure, has limitations. Discrepancies in the count are a common event and the sensitivity of the surgical count is only 77%. 1 We conducted a healthcare failure mode and effect analysis that identified potential failures in the processes of preventing retained sponges. 2 Distraction and multitasking were the most frequent causes, and are especially difficult, if not impossible, to eliminate. In their algorithm, Hariharan and Lobo propose using a standardised count process, the surgeon confirming the final count, and the use of radiography if the surgical count is incorrect. This poses a challenge clinically. In addition to the limitations of the count, the sensitivity of intraoperative radiography for detection of a retained surgical item is only 67%. 3 If we rely on these two interventions, we will not likely eliminate retained surgical items. The more sensitive postoperative survey images are taken outside of the operating theatre. This would require tremendous expense and a return trip to theatre if an item is identified. The algorithm would be enhanced by including methodological wound exploration by the surgeon, to search for sponges prior to closure, and a hard stop when a count is reported as being incorrect. We should also comprehensively evaluate adjunct technology. There are currently three adjunct technologies available to supplement the current processes for prevention of retained sponges. Hariharan and Lobo provide a comprehensive review of the evidence regarding two: the barcoded counting system and the radiofrequency identification system. The third, a radiofrequency (RF) detection system, involves low energy RF chips sewn into sponges and a scanner for detection of the sponges. Two scanners are available: a wand that is passed over the patient and a mat that is placed under the patient. Studies have found the sensitivity and specificity of the RF wand to be 100%, even in morbidly obese subjects. 4,5 The mat is slightly less sensitive for detection in morbidly obese than in non-morbidly obese patients (97% vs 100%). 5 RF technology has been shown to be highly effective in reconciling miscounts and preventing retained sponges. 6,7 In a study including 2,285 patients, no retained sponges occurred while using the RF technology within the 12 months of data collection. 7 I thank Hariharan and Lobo for highlighting a very important patient safety issue. Through teamwork and effective communication, we can improve patient care. However, as we cannot eliminate distraction and multitasking, we should evaluate adjunct technology to determine its applicability in the prevention of retained sponges.