Secondary Logo

Institutional members access full text with Ovid®

Share this article on:

The Frequency and Significance of Discrepancies in the Surgical Count

Greenberg, Caprice C. MD, MPH*†; Regenbogen, Scott E. MD†‡; Lipsitz, Stuart R. ScD*; Diaz-Flores, Rafael MD, MPH*†; Gawande, Atul A. MD, MPH*†

doi: 10.1097/SLA.0b013e318181c9a3
Original Article

Objective: To prospectively evaluate and accurately describe the rate and type of discrepancies encountered in the surgical count.

Introduction: Despite near-universal implementation of manual counting protocols for surgical instruments and sponges, incidents of retained sponges and instruments (RSI) persist. Retrospective analyses have shown that RSI are rare and most often involve final counts erroneously thought to be correct, leading some surgeons to question the value of counting. Crucial data regarding how often the surgical count successfully detects meaningful problems before the patient leaves the operating room is lacking.

Methods: Trained physician-observers documented prospective field observations during 148 elective general surgery operations using standardized intake forms. Data collection focused on the performance of the counting protocols, and the frequency and outcomes of discrepancies (instances in which a subsequent count does not agree with the previous count).

Results: A mean of 16.6 counting episodes occurred per case, occupying 8.6 minutes per case. A total of 29 discrepancies involving sponges (45%), instruments (34%) or needles (21%) were observed among 19 (12.8%) operations. Most discrepancies indicated a misplaced item (59%) as opposed to a miscount (3%) or error in documentation (38%). Each discrepancy took on average 13 minutes to resolve. Counting activities after personnel changes were significantly more likely to involve a discrepancy than those for which the original team was present.

Conclusions: One in 8 surgical cases involves an intraoperative discrepancy in the count. The majority of these discrepancies detect unaccounted-for sponges and instruments, which represent potential RSI. Thus, despite the recognized limitations of manual surgical counts, discrepancies should always prompt a thorough search and reconciliation process and never be ignored.

Prospective field observations were used to determine the rate and type of discrepancies encountered in the surgical count. One in 8 cases involves in intraoperative counting discrepancy. The majority of these detect unaccounted-for sponges and instruments, which represent potential retained sponges and instruments and should therefore never be ignored.

From the *Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; †Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts; ‡Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; and ¶Center for Outcomes and Policy Research, Dana Farber Cancer Institute.

Supported by a grant from SurgiCount Medical, Temecula, CA.

Reprints: Caprice C. Greenberg, MD, MPH., Brigham and Women's Hospital, Division of Surgical Oncology, 75 Francis Street, Boston, MA 02115. E-mail:

© 2008 Lippincott Williams & Wilkins, Inc.