The real truth about false correct counts

Unused white surgical sponges are hard to miss – until they turn red and conform to patient anatomy. An unreconciled count can easily be acted on per hospital protocol. But “false correct counts” – when numbers match and are perceived as correct, but aren’t – go undetected. This hidden danger prevents real-time corrective action and unintentionally increases the risk for all parties.

False correct counts
  • Risk factors
  • Supporting evidence

Risk factors for retained objects2,7,25

  • Incorrect counts
  • Breakdowns in communication, including hierarchy and intimidation
  • Staff changes
  • Emergent operations (i.e., no count)
  • Unexpected change in procedure direction
  • More than one surgical team or procedure
  • High blood loss (>500mL)
  • High BMI
  • Missing or compromised policies and procedures
  • Safety variance during procedure
  • Inadequate or incomplete staff training

Risk factors for retained instruments and sponges after surgery

Bar-coding surgical sponges to improve safety

„Guideline implementation, patient and worker safety prevention of retained surgical items

In a randomized controlled study, the bar-code system detected 32 count discrepancies versus 13 using the traditional protocol.19

  • “Most errors in healthcare are due to human factors. It’s like aviation – if you don’t do these checks, there can be human errors that happen.”28

    Valerie Marsh, RN, MSN, University of Michigan Health System

  • “Counting is a human process that’s very prone to error, especially in a busy environment where multiple things are happening simultaneously.”9

    Gail Horvath, MSN, RN, CNOR, CRCST Patient Safety Analyst, ECRI Institute

  • “Gawande et al. noted that in 88% of cases…the final count was erroneously believed to be correct. This implies a dual error: leaving an item in the patient, and a counterbalancing miscount that results in a false ‘correct’ count.”27

    WHO Guidelines for Safe Surgery

  • “The surgical tech attempted to recount 3 sponges that had already been counted. The barcode system alerted her to the duplication and avoided a potential error in the count.”19

    Caprice C. Greenberg, M.D., M.P.H, Brigham and Women’s Hospital

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