title: The frequency and significance of discrepancies in the surgical count.
abstract: OBJECTIVE
  To prospectively evaluate and accurately describe the rate and type of discrepancies encountered in the surgical count.
  
  
  BACKGROUND
  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.
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA. ccgreenberg@partners.org
authors.forename: Caprice C
authors.initials: CC
authors.lastname: Greenberg
authors.forename: Scott E
authors.initials: SE
authors.lastname: Regenbogen
authors.forename: Stuart R
authors.initials: SR
authors.lastname: Lipsitz
authors.forename: Rafael
authors.initials: R
authors.lastname: Diaz-Flores
authors.forename: Atul A
authors.initials: AA
authors.lastname: Gawande
mesh_terms: D000328:Adult; D005069:Evaluation Studies as Topic; D005260:Female; D005547:Foreign Bodies / Q000517:prevention & control*; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D008297:Male; D019300:Medical Errors / Q000517:prevention & control; D008875:Middle Aged; D009873:Operating Rooms; D011183:Postoperative Complications / Q000517:prevention & control; D011446:Prospective Studies; D018570:Risk Assessment; D017751:Safety Management; D012680:Sensitivity and Specificity; D013525:Surgical Instruments / Q000009:adverse effects / Q000706:statistics & numerical data*; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000379:methods; D015503:Surgical Sponges / Q000009:adverse effects / Q000706:statistics & numerical data*