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Application of an Engineering Problem-Solving Methodology to Address Persistent Problems in Patient Safety: A Case Study on Retained Surgical Sponges After Surgery

Anderson, Devon E. BSE*†; Watts, Bradley V. MD, MPH*‡

doi: 10.1097/PTS.0b013e3182831d9a
Original Articles

Despite innumerable attempts to eliminate the postoperative retention of surgical sponges, the medical error persists in operating rooms worldwide and places significant burden on patient safety, quality of care, financial resources, and hospital/physician reputation. The failure of countless solutions, from new sponge counting methods to radio labeled sponges, to truly eliminate the event in the operating room requires that the emerging field of health-care delivery science find innovative ways to approach the problem. Accordingly, the VA National Center for Patient Safety formed a unique collaboration with a team at the Thayer School of Engineering at Dartmouth College to evaluate the retention of surgical sponges after surgery and find a solution. The team used an engineering problem solving methodology to develop the best solution. To make the operating room a safe environment for patients, the team identified a need to make the sponge itself safe for use as opposed to resolving the relatively innocuous counting methods. In evaluation of this case study, the need for systematic engineering evaluation to resolve problems in health-care delivery becomes clear.

From the *VA National Center for Patient Safety, White River Junction, Vermont; †Thayer School of Engineering at Dartmouth College; and ‡Dartmouth Medical School, Department of Psychiatry, Hanover, New Hamphsire.

Correspondence: Bradley V. Watts, MD, MPH, Dartmouth Medical School, Hanover, NH (e-mail:

The author declare no conflict of interest.

This work was supported by the Veterans Health Administration’s National Center for Patient Safety. The views presented here are those of the authors and not necessarily the views of the Department of Veterans Affairs or of the United States government.

The development of a bioresorbable surgical sponge was funded by the VA National Center for Patient Safety and the Cook Engineering Design Center of the Thayer School of Engineering at Dartmouth College. The first author of this paper is an inventor of an “Absorbent Bioabsorbable Composite Surgical Biomaterial” filed under application number PCT/US11/28048.

© 2013 by Lippincott Williams & Wilkins