Counting matters: lessons from the root cause analysis of a retained surgical item.

Background: Retained surgical items (RSIs), such as a sponge, instrument, or needle, after a surgery or invasive procedure is an uncommon but potentially serious event associated with significant morbidity and mortality. A 27-year-old woman was discovered to have a retained vaginal sponge a week after she underwent the repair of a vaginal tear following normal vaginal delivery. The retained sponge was removed with no further complications.

Root Cause Analysis: The fundamental error involved the obstetric team's failure to perform the standard protocol of counting sponges before, as well as after, the procedure. This was attributed to a lack of reminders to perform the count, relatively recent implementation of the sponge-count policy, and a breakdown in teamwork and communication between physicians and nurses.

Corrective Actions: The corrective actions focused on systems improvement, as opposed to the human error of the memory lapse. The sponge-counting process was reinforced by incorporating a sign-out at the end of obstetric procedures to ensure that the counts have been done and any discrepancies addressed. A specialized delivery note with mandatory field to document sponge count was implemented in the electronic health record as an additional reminder. All staff participated in a teamwork and communication training program.

Tracking Compliance: Since the incident's occurrence in 2010, the staff has demonstrated 100% compliance with the corrective actions, and a retained surgical item complication has not recurred.

Conclusion: Individual accountability must be balanced with systems improvement, given that most medical errors are a result of fallible humans working in chaotic, unpredictable, and complex clinical environment.