“Each year in the U.S. there are over 1,500 incidents of surgical sponges being left inside patients after surgery resulting in deterioration of the health of the patients or even their deaths.”
In his article “Solving a Hundred Year Old Problem“, Zinovy Royzen outlines efforts that have been made to ensure that surgical sponges are never left behind in patients, including adding RFID tags and x-ray visible threads.
Another approach taken in 2012 is the Trust But Verify system described by Verna C. Gibbs M.D. This approach compares the number of empty sponge packets with the number of full sponge packets in a disposal pack. Instead of counting sponges, all that needs to be done is ensure that all the disposal packets are full. This disposal pack resembles a transparent hanging shoe organizer, except instead of shoes, it contains blood soaked sponges, ugh. I’ve spared you the picture.
This is an example of Principle 10 – Prior Action, wherein steps taken in advance prevent a problem or improve a result. In this case it makes it far less error prone to determine if the number of disposed sponges equal the number used.
Like so many applications of Principles, the solution seems obvious only in retrospect.