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.
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