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Please send a blank e-mail to: clinicalnursingcases-subscribe@topica.com Summary: Sponge Counts are a basic and critical safety measure during a surgical operation. In this case, the standard three counts were not performed. A sponge was left in the patient that would later lead to infection. When the issue went to court, the surgeon claimed "it was not his responsibility" to keep track of the sponges. The patient was admitted for surgical repair of a hernia. The operation was performed and the patient returned to the floors without obvious incident. "A hernia is a weakness or defect in the abdominal wall. It may be present from birth, or develop over a period of time. If the defect is large enough, abdominal contents such as the bowels, may protrude through the defect causing a lump or bulge felt by the patient. Hernias develop at certain sites which have a natural tendency to be weak; the groin, umbilicus (belly button), and previous surgical incisions."1 Post-operatively, the patient's incision would not heal. It would soon after start to display signs of active infection. "Postoperative wound infections have an enormous impact on patients' quality of life and contribute substantially to the financial cost of patient care. The potential consequences for patients range from increased pain and care of an open wound to sepsis and even death. Approximately 1 million patients have such wound infections each year in the United States, extending the average hospital stay by one week and increasing the cost of hospitalization by 20 percent."5 In investigating the situation, it would be found that a sponge had been left in the patient in the Operating Room. The patient sued both the surgeons and the nurses who had assisted in the procedure. "Materials counts are necessary to provide a standard of quality of care for the surgical patient and to provide a method of accounting for items placed on the sterile field for use on a surgical procedure."2 The patient claimed that substantial negligence on the part of the surgeon and nurses contributed to the sponge being missed and the development of complications. These complications, the plaintiff asserted, could have been avoided had proper procedure been adhered to. Specifically, if accurate sponge counts had been maintained and the missing sponge accounted for. Questions to be answered: 1. Who is primarily responsible during an operation to verify sponge counts and prevent one from inadvertently being left in a patient. 2. What are the explicit responsibilities of the Nurses and Physicians involved. For the operation in question, less than a dozen sponges were required. It was standard policy and procedure for three sponge counts to be performed during the operation. Anytime there is a discrepancy, the surgeon is to be notified immediately. Upon notification, it is his duty to the patient to resolve the discrepancy to the best of his ability. "In cases where there is an incorrect sponge count, wound closure absolutely must not be completed (unless the patient is unstable) until the missing sponge is accounted for. The surgeon should not pressure the nursing staff to ignore an incorrect count. If after appropriate steps have been taken to find the missing sponge or instrument and it is unsuccessful, every detail of the search should be documented and the surgery completed."3 Neither the nurses or the surgeon involved stated that they clearly remember the operation in question. The nurses' documentation of the event would show that only a single sponge count had been performed. The hospital policy in effect at the time required three per procedure. "The nurses count the unused, sterile sponges and note on a form that sponges were counted. When the surgeon completes the operation, the nurses do a second count by combining the number of unused sponges with the number of used sponges that have been removed from the patient. The total of the unused and used sponges must correspond to the number of sponges originally laid out prior to surgery. If the sponge count does not correspond, the surgeon is to be notified by the nurses. The nurses complete a third count shortly before the surgeon closes the incision. If nurses fail to account for a sponge, they are to report this directly to the surgeon. The nurses must note the results of the second and third counts on the same form on which they noted the initial count." The surgeon in his notes would document that a third count had been performed. He also documented that only after receiving this confirmation from the nurse, did he "close" up the patient. Is it plausible that the surgeon simply documented as if by habit, that the third count had been completed? A nurse documenting her assessment may sometimes by habit write "lungs clear" and "bowel sounds active x 4q." A moment later it is realized that in fact that was not the case and a correction made. Could the surgeon have fallen into the same trap? Upon discovery of the missed sponge and resulting infection, the surgeon insisted that "counting sponges" was not his responsibility. He went on to explain how in the body cavities they can become soiled with blood and take on the color of internal viscera. It was the surgeon's argument that it was the nurses' responsibility, not his that a proper sponge count be maintained. The surgeon, not the nurse is the person manipulating the sponges inside the patient's body. Can the surgeon release himself from responsibility for a sponge left in a patient because he relied on an inadequate sponge count given by a nurse? "Counting is the legal responsibility of the surgical team. Each institution must develop a policy and procedure for such counts and should include the delineation of materials counted, interval of counts, mechanism for performing the count , and documentation of the count status on the intraoperative record. The responsibility for accurate sponge counts rests with the circulating and scrub nurses. The operating room nurses are charged with the responsibility to ensure that no foreign objects remain in the body at the conclusion of surgery." The standards of care clearly state that if a sponge is missing, the nurse must notify the surgeon. There's little mystery to the fact that objects "left" inside patient's bodies can have catastrophic effects. The question remains, will the surgeon blaming the nurses get "off the hook" because a count was incorrectly reported? "While the surgeon may rely on the nurses' sponge counts the surgeon is ultimately responsible and liable for any foreign object left in a patient after surgery. Only x-ray detectable sponges should be utilized. A retained sponge occurs almost always in the presence of a normal sponge count." The trial court held, and appeals court confirmed that the surgeon shared in the negligence. The standard of care governing both the nurses and the physicians respectively had been breached. It is quite interesting to observe how quickly the physician sought to "dump" the blame on the nurses. The nursing staff by poorly documenting the sponge counts (omitting the 2nd and third) left themselves open to scrutiny. Had a proper count at least been documented, the surgeon would have had less ground to stand on when blaming the nurses for his mistake. Related Link Sections: Sponge Counts, Operating Room Links: Sources: 1. Pleatman, MD, Mark A. No date given. "Questions and Answers about Hernias." Retrieved May 23, 1999 from the World Wide Web: http://www.laparoscopy.com/pleatman/hernia.htm 2. San Antonio Chapter of AORN. No date given. "Counts, Sponge, Needle, Instrument." Retrieved May 23, 1999 from the World Wide Web: http://www.connecti.com/~remmert/p0008.txt 3. The Standard of Care. August 1998. "Retained Surgical Foreign Body." Retrieved May 23, 1999 from the World Wide Web: http://www.standardofcare.com/publications/980801.htm 4. 38 RRNL 2 (July 1997 5. Woods, Ronald K. and Dellinger, E. Patchen. June 1998. "Current Guidelines for Antibiotic Prophylaxis of Surgical Wounds." Retrieved May 23, 1999 from the World Wide Web: http://www.aafp.org/afp/980600ap/woods.html
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Created on Saturday, May 22, 1999 Last updated by Andrew Lopez, RN on Monday, February 28, 2011 | 
