BAUTISTA, Jesther Rowen B.

OR, ITRMC, 7-3

BSN III-1

Sponge Count Off, Patient Develops Sepsis, Surgeon Blames Nurse.

Johnston v. Southwest Louisiana Assn. 693 So. 2d 1195 –LA

Sponge Counts are a basic and critical safety measure during a surgical
operation.  In this case, the standard three counts were not performed.  A sponge
was left in the patient that would later lead to infection.  When the issue went to
court, the surgeon claimed "it was not his responsibility" to keep track of the
sponges.

The patient was admitted for surgical repair of a hernia.  The operation was
performed and the patient returned to the floors without obvious incident.

"A hernia is a weakness or defect in the abdominal wall. It may be present

from birth, or develop over a period of time. If the defect is large enough, abdominal
contents such as the bowels, may protrude through the defect causing a lump or
bulge felt by the patient. Hernias develop at certain sites which have a natural
tendency to be weak; the groin, umbilicus (belly button), and previous surgical
incisions."

Post-operatively, the patient's incision would not heal.  It would soon after
start to display signs of active infection.

In investigating the situation, it would be found that a sponge had been left in
the patient in the Operating Room.  The patient sued both the surgeons and the
nurses who had assisted in the procedure.

The patient claimed that substantial negligence on the part of the surgeon
and nurses contributed to the sponge being missed and the development of
complications.  These complications, the plaintiff asserted, could have been avoided
had proper procedure been adhered to.  Specifically, if accurate sponge counts had
been maintained and the missing sponge accounted for.

For the operation in question, less than a dozen sponges were required.  It
was standard policy and procedure for three sponge counts to be performed during
the operation.

Anytime there is a discrepancy, the surgeon is to be notified immediately. 

Upon notification, it is his duty to the patient to resolve the discrepancy to the best of
his ability.

"In cases where there is an incorrect sponge count, wound closure absolutely
must not be completed (unless the patient is unstable) until the missing sponge is
accounted for. The surgeon should not pressure the nursing staff to ignore an
incorrect count. If after appropriate steps have been taken to find the missing sponge
or instrument and it is unsuccessful, every detail of the search should be
documented and the surgery completed."
 Neither the nurses or the surgeon involved stated that they clearly remember
the operation in question.   The nurses' documentation of the event would show that
only a single sponge count had been performed.  The hospital policy in effect at the
time required three per procedure.

"The nurses count the unused, sterile sponges and note on a form that
sponges were counted.   When the surgeon completes the operation, the nurses do
a second count by combining the number of  unused sponges with the number of
used sponges that have been removed from the patient.  The total of the unused and
used sponges must correspond to the number of sponges originally laid out prior to
surgery.

If the sponge count does not correspond, the surgeon is to be notified by the
nurses.  The nurses complete a third count shortly before the surgeon closes the
incision.   If nurses fail to account for a sponge, they are to report this directly to the
surgeon.  The nurses must note the results of the second and third counts on the
same form on which they noted the initial count."

The surgeon in his notes would document that a third count had been
performed.  He also documented that only after receiving this confirmation from the
nurse, did he "close" up the patient.

Is it plausible that the surgeon simply documented as if by habit, that the third
count had been completed?  A nurse documenting her assessment may sometimes
by habit write "lungs clear" and "bowel sounds active x 4q."  A moment later it is
realized that in fact that was not the case and a correction made.  Could the surgeon
have fallen into the same trap?

Upon discovery of the missed sponge and resulting infection, the surgeon
insisted that "counting sponges" was not his responsibility.  He went on to explain
how in the body cavities they can become soiled with blood and take on the color of
internal viscera.

It was the surgeon's argument that it was the nurses' responsibility, not his
that a proper sponge count be maintained.  The surgeon, not the nurse is the person
manipulating the sponges inside the patient's body.  Can the surgeon release
himself from responsibility for a sponge left in a patient because he relied on an
inadequate sponge count given by a nurse?

The standards of care clearly state that if a sponge is missing, the nurse must
notify the surgeon.  There's little mystery to the fact that objects "left" inside patient's
bodies can have catastrophic effects.

The question remains, will the surgeon blaming the nurses get "off the hook"
because a count was incorrectly reported?

"While the surgeon may rely on the nurses' sponge counts the surgeon is
ultimately responsible and liable for any foreign object left in a patient after surgery.
Only x-ray detectable sponges should be utilized. A retained sponge occurs almost
always in the presence of a normal sponge count."
 The trial court held, and appeals court confirmed that the surgeon shared in
the negligence.  The standard of care governing both the nurses and the physicians
respectively had been breached.

It is quite interesting to observe how quickly the physician sought to "dump"

the blame on the nurses.

Source: http://www.nursefriendly.com/nursing/clinical.cases/052399.htm