Preventing Retained Surgical Items Through the Development of a Safer Telescopic Sponge‐Counting System

A retained surgical item (RSI) remains a serious patient safety risk in perioperative nursing, with surgical sponges representing the most common RSI. After an RSI event involving a sponge occurred at a large academic medical center, a root cause analysis identified the stacking of sponge bags as a contributing factor. The nurse innovator was tasked with finding a solution. A telescopic sponge-counting system (SCS) prototype, featuring expandable arms, allowed visualization of 120 sponges without stacking bags. A three-phase evaluation was conducted: a staff assessment of the standard SCS currently in use and testing of the initial SCS prototype in a simulated environment; beta testing the prototype in clinical practice; and chart audits comparing outcomes between the standard SCS and the prototype. The SCS prototype demonstrated improved visibility, functionality, safety, and staff satisfaction during practice. This SCS has the potential to reduce sponge-related RSIs by eliminating the stacking of sponge bags.