Designing a Safer Process to Prevent Retained Surgical Sponges: A Healthcare Failure Mode and Effect Analysis

A retained surgical sponge is a sentinel event that can result in serious negative outcomes for the patient. Current standards rely on manual counting, the accuracy of which may be suspect, yet little is known about why counting fails to prevent retained sponges. The objectives of this project were to describe perioperative processes to prevent retained sponges after elective abdominal surgery; to identify potential failures; and to rate the causes, probability, and severity of these failures. A total of 57 potential failures were identified, associated with room preparation, the initial count, adding sponges, removing sponges, the first closing count, and the final closing count. The most frequently identified causes of failures included distraction, multitasking, not following procedure, and time pressure. Most of the failures are not likely to be affected by an educational intervention, so additional technological controls should be considered in efforts to improve safety.