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Recommended Practices for Sponge,Sharp, and Instrument Counts

nificantly reduce, if not eliminate, these inci-dents.v' The "captain of the ship" doctrine is nolonger assumed to be true, and members of theentire surgical team can be held liable in litigationfor retained foreign bodies.':" All team membersshould be committed to and involved in establish-ing meaningful policies and procedures related tosurgical counts.""

The following recommended practices weredeveloped by the AORN Recommended Prac-tices Committee and have been approved by theAORN Board of Directors. They were presented

as proposed recommended practices for commentsby members and others. They are effective January1,2006.

These recommended practices are intended asachievable recommendations representing what isbelieved to be an optimal level of practice. Policiesand procedures will reflect variations in practicesettings and/or clinical situations that determinethe degree to which the recommended practices((In be implemented.

AORN recognizes the numerous settings inwhich perioperative nurses practice. These recom-mended practices are intended as guidelines thatdie adaptable to various practice settings. Thesepractice settings include traditional operatingrooms, ambulatory surgery centers, physicians'offices, cardiac catheterization suites, endoscopysuites, radiology departments, and all other areaswhere operative and other invasive proceduresnl.ly be performed.

PurposeIhese recommended practices provide guidance topnioperative registered nurses in performingfiponge, sharp, and instrument counts in their prac-tl.c settings. Counts are performed to account for1\11 items and to lessen the potential for injury to111/' patient as a result of a retained foreign body.t hf~expected outcome of primary importance tolhh recommended practice is outcome 02, "Thej!.ltknt is free from signs and symptoms of injuryrlue 10 extraneous objects." Complete and accu-fllll' counting procedures help promote optimalp('I'\np rative patient outcomes and demonstratetll() p rioperative practitioner's commitment topa!itlrll safety.

Legislation does not prescribe how counts\.lJhnu!d he performed, who should perform them, or'fh'(tlil that they need to be performed. The law

--''''!/Uil\'' only that foreign bodies not be negligently"ldl III patients.' The doctrine of res ipsa loquitur

.f t,/ "the thing speaks for itself") is most applicableHI tft!il;lS involving retained foreign objects, render-l's{ thiJ~" litigations nearly indefensible.s- RetainedlJ{jr{'t~ are considered a preventable occurrence,'Ill I r.ircfu] counting and documentation can sig-

iJ /~jl'/()peralive Standards and Recommended Practices.. J jHvi';"d: November 2005. © AORN, Inc. All rights reserved.

Recommendation I

Sponges should be counted on all procedures inwhich the possibility exists that a sponge could beretained.

1. Sponge counts should be performed• before the procedure to establish a baseline,• before closure of a cavity within a cavity,• before wound closure begins,• at skin closure or end of procedure, and• at the time of permanent relief of either the

scrub person or the circulating nurse(although direct visualization of all itemsmay not be possible).

2. Initial sponge counts should be performed andrecorded, establishing a baseline for subse-quent counts on all procedures in which thepossibility exists that a sponge could beretained. Policies in the health care organiza-tion may identify situations in which this possi-bi I ity does not exist and counts are notrequired."

3. Accurately accounting for sponges throughouta surgical procedure should be a priority of thesurgical team to minimize the risks of aretained sponge.v-"-" The Institute of Medicinehas identified avoiding injuries from the carethat is intended to help patients to be one ofsix aims to a better health care system."

4. Established policies in the health care organi-zation may define when additional countsmust be performed or may be omitted (eg, cys-toscopy, ophthalmology)." Closed claim stud-ies conducted during the past 20 years havedemonstrated that roughly two-thirds ofreported cases of retained surgical items areattributed to sponges.':":" Although the major-ity of retained sponges are found in theabdomen and pelvis, there are reports in the

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literature discussing retained sponges in thevagina, thorax, spinal canal, face, brain, andextrem ities.5.21-27

5. Sponges should be separated, counted audibly,and concurrently viewed during the count pro-cedure by two individuals, one of whom shouldbe a registered nurse circulator.v"= Concurrentverification of counts by two individuals lessensthe risk of inaccurate counts. Separating spongesduring the baseline count helps to determinewhether a sponge has been added to or deletedfrom a sterilized package.v-"> Use of a pock-eted bag or other system for separating usedsponges may facilitate visualization for counting.Separating sponges after use minimizes errorscaused by sponges sticking together.

6. When additional sponges are added to thefield, they should be counted at that time andrecorded as part of the count documentation tokeep the count current and accurate"

7. Peri operative personnel should count allprepackaged sterile sponges for accuracy. Anypackage containing an incorrect number ofsponges should be removed from the field,bagged, labeled, and isolated from the rest ofthe sponges in the OR. Containing and isolat-ing the entire package helps reduce the poten-tial for error in subsequent counts."

8. Sponge counts should be conducted in thesame sequence each time as defined by thefacility. The counting sequence should be in alogical progression (eg, from large to small orfrom proximal to distal). A standardized countprocedure, following the same sequence,assists in achieving accuracy, efficiency, andcontinuity among peri operative team mem-bers." Studies in human error have shown thatall errors involve some kind of deviation fromroutine practice.31(p57)

9. All sponges used during a surgical procedureshould be x-ray-detectable. Radiopaque indi-cators facilitate locating an item presumed lostor left in the surgical field when a count dis-crepancy occurs. X-ray-detectable spongesshould not be used as dressings. The use ofx-ray-detectable sponges as surface dressingsmay invalidate subsequent counts if the patient

...- - ---------._.--..

is returned to the OR. X-ray-detectable spongesused as dressings may appear as foreign bodieson postoperative x-ray studies.29.32-34

10. Only towels with radiopaque markers shouldbe used in the wound. If towels are used in theopen wound, they should be included in thecount as miscellaneous items and should beeasily distinguishable from other towels.29.32.33

11. Sponges should be left in their original config-uration and should not be cut. Altering asponge invalidates subsequent counts andincreases the risk of a portion being retained inthe wound.":"

12. Nonradiopaque gauze dressing materials shouldbe withheld from the field until the wound isclosed or the case is completed. Keeping dress-ing materials separated from the actual countedsponges will help prevent intermingling with thesponges used in the procedure.'

13. All counted sponges should remain within theOR or sterile field during the procedure. Linenand waste containers should not be removedfrom the room until counts are completed andresolved. Confinement of all counted spongesto the OR helps eliminate the possibility of acount discrepancy."

14. Counted sponges should not be used as postop-erative packing. In certain circumstances, suchas when counted sponges are intentionally usedas packing and the patient leaves the OR withthis packing in place, the number and types ofsponges retained and the reason for the varia-tion should be documented on the intraopera-tive record as correct and confirmed by the sur-geon"·14.35When the patient returns to surgeryand the packed sponges are removed, the num-ber and types should be reconciled with thenumber and types removed. The number andtypes removed should be noted in the currentpatient's record. The sponges removed shouldbe isolated and not included in the counts forthe subsequent procedure. The count on thesubsequent procedure should be noted as cor-rect after all sponges have been accounted for. Ifthe sponges are removed in an area other thanthe OR, the number removed should be notedon the patient record.

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15. Sponges should be removed from the OR atthe end of the procedure. Removing spongesfrom the OR at the end of the procedure helpsprevent potential count discrepancies duringsubsequent procedures." "

16. Contaminated sponges must be handled anddisposed of according to the BloodbornePathogens Standard of the Occupational Safetyand Health Administration (OSHA); AORN's"Recommended practices for environmentalcleaning in the surgical practice setting?" and"Recommended practices for standard andtransmission-based precautions in the perioper-ative practice setting'?': and facility policies andprocedures. The use of leak-proof, tear-resistantcontainers and personal protective equipment'(PPE)can help prevent environmental contami-nation and reduce the risk of personnel expo-sure to potentially infectious material.":"

Recommendation II

Sharps and other miscellaneous items should becounted on all procedures.

1. Sharps and miscellaneous items (eg, vessel clipbars, vessel loops, umbilical and hernia tapes,vascular inserts, cautery scratch pads, trocarsealing caps) should be counted• before the procedure to establish a baseline,• before closure of a cavity within a cavity,• before wound closure begins,• at skin closure or end of procedure, and• at the time of permanent relief of the scrub per-

son and/or circulating nurse (although directvisualization of all items may not be possible).

2. Initial sharps counts should be performed andrecorded on all procedures. Performing countsconstitutes a primary and proactive injury-prevention strategy.' Counting sharps and mis-cellaneous items is not only important inpreventing foreign body retention; the continu-ous accounting for these items can lesseninjuries to those scrubbed in the sterile field. Asmany as 78% of reported needle-stick exposuresoccur to members of the surgical team.39•40 Accu-rately accounting for sharps during a surgicalprocedure is a primary responsibility of the peri-operative nurse and the surgical team members.


3. Sharps and miscellaneous items should becounted audibly and viewed concurrently bytwo individuals, one of whom should be a reg-istered nurse circulator. Concurrent verificationof counts by two individuals lessens the risk forcount discrepancies.'

4. Additional sharps and miscellaneous itemsadded to the field should be counted whenadded and recorded as part of the count docu-mentation.

5. Suture needles should be counted andrecorded according to the number marked onthe outer package and verified by the scrubperson when the package is opened." Viewingeach needle will help ensure an accurate nee-dle count. Using empty suture packages to rec-tifya discrepancy in a closing needle count isnot recommended." The actual number of nee-dles may not be the same as the number ofempty packages.

6. The scrub person should be able to account forall sharps on the sterile field. Sharps remainingunconfined on the sterile field may be uninten-tionally introduced into the incision ordropped on the floor or may penetrate barriers.

7. Whenever possible, sharps must be handed toand from the surgeon on an exchange basisusing a "neutral zone" or "hands-free" tech-nique."" Passing sharps to the surgeon on anexchange basis will lessen the possibility of alost sharp item and prevent injury to the surgi-cal team members at the sterile field."

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8. Sharps counts should be conducted in the samesequence each time as defined by the facility.The counting sequence should be in a logicalprogression (eg, from large to small item size orfrom proximal to distal from the wound). A stan-dardized count procedure, following the samesequence, assists in achieving accuracy, effi-ciency, and continuity among perioperativeteam members." Studies in human error haveshown that all errors involve some kind of devi-ation from routine practice.31(p57)

9. Members of the surgical team should accountfor sharps or other miscellaneous items thatmay have been broken or become separated

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within the confines of the surgical site in theirentirety. Breakage and/or separation of partscan occur during open as well as minimallyinvasive surgical procedures. Verification thatall broken parts are present or accounted forhelps prevent unintentional retention of a for-eign body within the patient.'>" ..•7

10. Open sharps on the sterile field should be con-fined and contained, Used sharps on the sterilefield should be kept in a disposable puncture-resistant container. Collecting used needles ina container helps ensure their containment onthe sterile field and lessens the risk of injury topersonnel at the sterile field.":"

11. All counted sharps should remain within theOR and/or sterile field during the procedure. Ifa sharp is passed or dropped off the sterilefield, the circulating nurse should retrieve it ina safe manner, show it to the scrub person, andisolate it from the field to be included in thefinal count. Linen or waste containers shouldnot be removed from the OR until all countsare completed and resolved and the patienthas been taken from the room. Confinement ofall sharps to the OR helps minimize the possi-bility of a count discrepancy."

12, Sharps must be handled according to theOSHA Bloodborne Pathogens Standard. Properuse, handling, and disposal of contaminatedsharps help minimize the risk of exposure tobloodborne pathogens from patient to healthcare worker and from health care worker topatient." AORN's "Recommended practices forstandard and transmission-based precautionsin the perioperative practice setting?" shouldbe followed, Sharps should be disposed ofaccording to AORN's "Recommended prac-tices for environmental cleaning in the surgicalpractice setting.'?'

Recommendation III

Instruments should be counted for all proceduresin which the likelihood exists that an instrumentcould be retained.

1. Instrument counts should be performed• before the procedure to establish a baseline,• before wound closure, and+Petient end vvorker S,fety

• when feasible, at the time of permanent reliefof the scrub person and/or circulating nurse,

Instrument counts protect the patient byreducing the likelihood that an instrument willbe retained in the patient. Instrument countsare a proactive injury-prevention strategy.'Retention of surgical instruments accounts forapproximately one-third of retained item casereports.' Case studies demonstrate that manytypes and sizes of instruments have beenfound, ranging from small serrifine clamps tomoderately sized hemostats (ie, 6 to 10 inches)to 13-inch-long retractors.w"

2, Instruments should be counted audibly andviewed concurrently by two individuals, one ofwhom should be a registered nurse circulator.Concurrent verification of counts by two indi-viduals assists in ensuring accurate counts.'

3. Instruments should be counted when sets areassembled for sterilization. This assemblycount provides a basic reference for the instru-ment set and is not to be considered the initialcount before the surgical procedure. A countperformed outside the OR that is consideredan initial count increases the number ofvariables that can contribute to a count dis-crepancy and unnecessarily extends responsi-bility to personnel not involved in directpatient care,"

, 4, Initial counts in the OR should be performedto establish a baseline for subsequent counts,including minimally invasive procedures (eg,laparoscopy, thoroscopy). The possibility of anyincision being extended to allow for a moreextensive procedure than anticipated supportsthepractice of performing an initial count forall procedures.

5. Individual pieces of assembled instruments (eg,suction tips, wing nuts, blades, sheathes) shouldbe accounted for separately on the count sheet.Removable instrument parts can be purposefullyremoved or become loose and fall into thewound or onto or off the sterile field."

6, When additional instruments are added to thefield, they should be counted when added andrecorded as part of the count documentation,


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7. Members of the surgical team should account forinstruments that may have been broken orbecome separated within the confines of the sur-gical site in their entirety. Breakage and/or sepa-ration of parts can occur during open as well asminimally invasive surgical procedures. Verifica-tion that all broken parts are present oraccounted for helps prevent unintentional reten-tion of a foreign body within the patient.">"

8. Instrument counts should be conducted in thesame sequence each time as defined by theorganization. The counting sequence should bein a logical progression (eg, from large to smallitem size or from proximal to distal from thewound). A standardized count procedure, fol-lowing the same sequence, assists in achievingaccuracy, efficiency, and continuity among peri-operative team members." Studies in humanerror have shown that all errors involve somekind of deviation from routine practice.v="

9. The final instrument count should not be con-sidered complete until those instruments usedin closing the wound (eg, malleable retractors,needle holders, scissors) are removed from thewound and returned to the scrub person.

10. All counted instruments should remain within theOR during the procedure until all counts arecompleted and resolved. If a counted instrumentis passed or inadvertently dropped off the sterilefield, the circulating nurse should retrieve it, showit to the scrub person, and isolate it from the fieldto be included in the final count." Confinementof all counted instruments to the OR helps elimi-nate the possibility of a count discrepancy."

11. All instruments should be accounted for andremoved from the room during end-of-proce-dure cleanup. Accounting for all instrumentsfacilitates inventory control and patient safety.Removing all instruments from the room helpsavoid potential count discrepancies duringsubsequent procedures."

12. Instrument sets should be standardized withthe minimum variety and number of instru-ments needed for the procedure. Instrumentsthat are not routinely used on proceduresshould be deleted from sets. Reducing thenumber and types of instruments and stream-


lining standardized sets improves ease and effi-ciency of counting." Specialty instruments, ifneeded, can be opened and added to thecount at the time of the procedure."

13. Preprinted count sheets that are identical to thestandardized sets should be used to record thecounted items. Preprinted count sheets provideorganization and efficiency, which are key topreventing unnecessary delays: The circulatingnurse should record only the number of instru-ments opened for the procedure. Additionalinstruments requested by the surgeon shouldbe counted and added to the preprinted countsheet separately."

, 14. Contaminated instruments must be handledaccording to the OSHA Bloodborne PathogensStandard. Proper use and handling 'of contami-nated instruments help minimize the risk ofexposure to bloodborne pathogens from patientto health care worker and from health care

. worker to patient." Contaminated instrumentsshould be handled according to AORN's"Recommended practices for cleaning and car-ing for surgical instruments and powered equip-ment'?? and "Recommended practices for clean-ing and processing endoscopes and endoscopeaccessories,'?' as well as the institution's policiesand procedures." Contaminated instrumentsmay expose personnel to harmful pathogens."

15. Alternative measures should be established tominimize the risk of retained instruments dur-ing procedures in which accurately accountingfor instruments is not achievable (eg, anterior-posterior spinal procedures). These measuresshould include the use of an intraoperative x-ray, read by a radiologist, before the patient isdischarged from the OR.

16. Organizations should define when instrumentcounts should be performed for pediatricpatients. Instrument counts may be deferredwhen there is no perceived risk of retainedinstruments.

11, ''.

Recommendation IVAdditional measures for investigation, reconcilia-tion, documentation, and prevention of retainedsurgical items should be taken.

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1. When a discrepancy in the count(s) is identified,the surgical team is responsible for carrying outstepsto locate the missing item.4,13,45,slProceduralsteps include, but are not limited to,• count discrepancy reported to surgeon and

surgical team;• procedure suspended, if patient's condition

permits;• manual inspection of the operative site;• visual inspection of the area surrounding the

surgical field, including floor, kick buckets,and linen and trash receptacles;

• if the patient's condition permits, intraopera-tive x-ray taken and read before patientleaves the OR or, if the patient's condition isunstable, an x-ray should be taken as soonas possible;

• documentation of all measures taken andoutcomes on patient's record;

• reporting of incident following organizationpolicy; and

• review of incident or near miss for cause,effect, and prevention.

2. The peri operative registered nurse circulatorshould inform and receive an acknowledgmentfrom the surgeon and team as soon as a dis-crepancy in a surgical count (ie, sponge,sharps, instrument) is identified.3,4,14,28,s2

3. The perioperative registered nurse circulator andscrub person should ask the surgeon to conducta manual search of the wound to locate themissing item(s). The scrub person and periopera-tive registered nurse circulator should do a man-ual and visual search, respectively, of the sterilearea surrounding the wound and the remainderof the sterile field. The perioperative registerednurse circulator should conduct a search of thenonsterile areas of the room in an attempt tolocate the item(s),3,18,20,4s,s2

4. If the item is not recovered, an intraoperative x-ray should be taken before the final closure ofthe wound. It should be specified that the pur-pose of the x-ray is to rule out a retained for-eign body (eg, needle, sponge, instrument). Thisx-ray should be read by a radiologist. Studiesshow greater accuracy when x-rays are read bya radiologist.4,s,14.20,33In the case of missing nee-dles, there is no definitive evidence as to how+Pstient end vvorker Seiety

effective x-rays are in detecting small sutureneedles. Studies done in recent years havedemonstrated that needles 17 mm and smallermay not be consistently visible on an x-ray."-"

5. Following organizational policy, documenta-tion of a count discrepancy should include allthe measures taken to recover the missing itemand communications made regarding the out-come. Such documentation is consideredsound professional practice and demonstratesthat all reasonable efforts were made to protectthe patient's safety.2,4,17,34,48

6. A critical investigation should be conducted ofany patient safety incident process.vv'?' Error andnear-miss reporting are the first steps to address-ing error reduction.":" The distraction-proneenvironment of the OR means that performingroutine tasks, such as surgical counts, can beconsidered at risk for error." Errors can bedivided into two categories: those at the humaninterface in a complex system (ie, active), andthose representing failed system design (ie,latent)." Elements of the root cause analysis toolshould be considered in addressing the con-tributing causes (eg, human, process, system) andin identifying risks and preventive measures."Multidisciplinary teams should be involved inthe process of review and address any changes inpolicy that can improve patient safety."

7. Additional measures should be established tominimize the risk of retained items in high-risksituations. The following situations have beenidentified through research to be of higher riskfor retained foreign bodies:• the emergent nature of a procedure,• an unexpected change in the procedure, and• patient obesity.'

8. Internal data from adverse events and nearmisses should be reviewed to identify high-risksituations within the organization. Health careorganizations should identify conditions or sit-uations that pose an increased risk for retainedforeign bodies. Health care organizationsshould establish measures to be taken, in addi-tion to a count, for identified high-risk situa-tions. These measures should include an intra-operative x-ray for foreign body, read by a staffradiologist, before the patient leaves the OR. In


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one study, three of 29 x-rays were read as neg-ative when a retained sponge actually waspresent." Therefore, x-ray alone may be insuffi-cient to detect a retained item.

Recommendation V

Sponge, sharp, and instrument counts should bedocumented on the patient's intraoperative recordby the registered nurse circulator.

1. The uniform perioperative nursing vocabularyshould be used to document counts on the intra-operative patient record. The perioperative nurs-ing vocabulary is a clinically relevant and empir-ically validated standardized nursing language.This standardized language consists of the Peri-operative Nursing Data Set (PNDS) and includesperioperative nursing diagnoses, interventions,and outcomes. The expected outcome of pri-mary importance to this recommended practiceis outcome 02, "The patient is free from signsand symptoms of injury due to extraneousobjects." This outcome falls within the domain ofSafety (D1). The associated nursing diagnosis isX29, "Risk of injury." The associated interven-tions that may lead to the desired outcome mayinclude (193) "Performs required counts."

2. Documentation of counts should include, butnot be limited to,• types of counts (ie, sponges, sharps, instru-

ments, miscellaneous items) and number ofcounts;

• names and titles of personnel performing thecounts;

• results of surgical item counts;• notification of the surgeon;• instruments intentionally remaining with the

patient or sponges intentionally retained aspacking;

• actions taken if count discrepancies occur;• outcome of actions taken; and• rationale if counts are not performed or

completed as prescribed by policy.

3. Accurate documentation serves several pur-poses, including evidence of the patient's treat-ment, the basis of the plan of care, communica-tion to all caregivers, protection from liability,and a link to reimbursement.":" Documentation


of nursing activities related to the patient's peri-operative care provides an accurate picture ofthe nursing care administered and provides amechanism for comparing actual versusexpected outcomes."

4. Justification for omission of counts in an emer-gency should be documented, Extreme patientemergencies may necessitate omission of countsto preserve a patient's life or limb, Documentingthe omission and reasons for the variation pro-vides a record of the occurrence and an alert tosubsequent caregivers that the patient may be atan increased risk for a retained foreign body.',

Recommendation VI .

Policies and procedures for sponge, sharp, andinstrument counts should be developed, reviewedperiodically, revised as necessary, and readilyavailable in the practice setting.

1. These policies and procedures should include,but not be limited to,• items to be counted,• directions for performing counts (eg,

sequence, item grouping),• procedures in which baseline and/or subse-

quent counts may be exempt,• alternative or additional safety measures for

special circumstances/• nursing actions and procedures for count

discrepancy reconciliation, and• competency validation.

Policies and procedures establish authority,responsibility, and accountability and serve asoperational guidelines. Policies and proceduresalso assist in the development of patient safety,quality assessment, and quality improvementactivities." Nurses should collaborate with allmembers of the health care team to developpolicies that address surgical counts.'>"

2. Policies and procedures should be written toinclude organ procurements. Counted itemscould be at risk for being retained and sentwith the donated organ(s), retained in thedonor, or left in the OR.

3, Practices, policies, and procedures are subject tochange with the advent of new technologies,

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4. An introduction and review of policies andprocedures should be included in orientationand ongoing education of peri operative per-sonnel to assist them in obtaining knowledgeand developing skills and attitudes that affectpatient outcomes.

Glossary

Instruments: Surgical tools or devices designedto perform a specific function, such as cutting, dis-secting, grasping, holding, retracting, or suturing.

Sharps: Items with edges or points capable ofcutting or puncturing through other items. In thecontext of surgery, items include, but are not lim-ited to, suture needles, scalpel blades, hypodermicneedles, electrosurgical needles and blades, andsafety pins.

Sponges: Soft goods (eg, gauze pads, cottonoids,peanuts, dissectors, tonsil and laparotomy sponges)used to absorb fluids, protect tissues, or apply pres-sure or traction.

Minimally invasive surgery: Includes laparoscopyand other procedures that involve small incisions andendoscopic instrumentation performed in the OR.

Miscellaneous items: Includes vessel clip bars,vessel loops, umbilical and hernia tapes, vascularinserts, cautery scratch pads, trocar sealing caps,and any other small items that have the potentialfor being retained in a surgical wound.

Neutral 'zone (synonym: hands-free technique):A safe work practice control technique used toensure that the surgeon and scrub person do not'touch the same sharp instrument at the same time.This technique is accomplished by establishing adesignated neutral zone on the sterile field andplacing sharp items within the zone for transfer ofthe item between scrubbed personnel.

Near miss: An occurrence that could haveresulted in an accident, injury, or illness but didnot by chance, skillful management, or timelyintervention.

Root cause analysis: A retrospective approach toerror analysis that focuses on failures of systemdesign as related to common root causes ofadverse events.

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The Perioperative Nursing Vocabulary, second ed (Den-ver: AORN, Inc, 2002).+Petient and Worker Seietv

2. E K Murphy, "Operating room records, countscause concern," (OR Nursing Law) AORN journal 51(lune 1990) 1606-1612.

3. J Zuffoletto, "Nurses' vs surgeons' responsibilityfor sponge counts," (OR Nursing Law) AORN journal 57(lune 1993) 1457-1458.

4. ECRI, "Sponge and instrument counts," (RiskAnalysis, Surgery and Anesthesia 5) Healthcare RiskControl 4 Uanuary 1996) 1-9.

5. A A Gwande et ai, "Patient safety: Risk factors forretained instruments and sponges after surgery," TheNew England journal of Medicine 348 (january 2003)229-235.

6. E K Murphy, "'Captain of the ship' doctrine con-tinues to take on water," (OR Nursing Law) AORN jour-nal74 (October 2001) 525-528.

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Irani, Archer, Bruno, and Del Rosario, 298 NJ Super650; 690 A2d 147; 1997 NJ Super (New Jersey, 1997).

9. Stafford v Molinoff and Halfen, 228 AD2d 662;645 NYS2d 313; 1996 NY App Div (New York, 1996).10, Ravi v Vaughn and Foxworthy v Athens-Limestone

Hospital v Coates, 662 So2d 218; 1995 (Alabama, 1995).11. L E Rozovsky, F A Rozovsky, "The surgeon and the

nurse share the blame: A case of a retained sponge,"Canadian Operating Room Nursing journal 9 (Septern-ber/October 1991) 20-21 .

12. A D Tammelleo, ed, "The surgeon's nondelegableresponsibility for the sponge count," The Regan Reporton Nursing Law 38 Uuly 1997) 2.

13. S C Beyea, "Counting instruments and sponges,"(Patient Safety First) AORN journal 78 (August 2003)290-294,

14. J K Cherry, "Surgery: Foreign object retention," TheDoctors Company, http://www.thedoctors.com/risk/specialty/generalsurgeryI}4219.asp (accessed 8 Sept 2005).

15. E K Murphy, "Nurses' liability for inaccuratecounts," (OR Nursing Law) AORN journal 51 (April1990) 1067-1069.

16. E K Murphy, "Liability for inaccurate counts; assis-tant circulators," (OR Nursing Law) AORN journal 53(lanuary 1991) 157-161.

17., Institute of Medicine, Crossing the Quality Chasm:A New Health System for the 21st Century (Washington,DC: National Academy Press, 2001).

18, C W Kaiser et al, "The retained surgical sponge,"Annals of Surgery 224 (luly 1996) 79-84.

19. V C Gibbs, "Did we forget something? Retainedsurgical sponge," AHRQ Web M&M: Case and Com-mentary, http://www.webmm.ahrq.govicase.aspx?caseID=27&searchStr=%22 reteined+surgicel+sponge%22+AND+Gibbs (accessed 8 Sept 2005).

20. P R Lauwers, R H Van Hee, "Intraperitonealgossypibomas: The need to count sponges," World jour-nal of Surgery 24 (May 2000) 512-527.

21. A P Zbar et al, "Gossypiboma revisited: A casereport and review of the literature," journal of the Royal


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College of Surgeons of Edinburgh 43 (December 1998)417-418.

22. B A Hemelt, M A Finan, "Abdominal sacralcolpopexy resulting in a retained sponge: A case report,"The journal of Reproductive Medicine 44 (November1999) 983-985.

23. S R Kim, H K Baik, Y W Park, "Retained surgicalsponge presenting as a pelvic tumor after 25 years,"International journal of Gynecology and Obstetrics 82(August 2003) 223-225.

24. H Nomori et ai, "Retained sponge after thoraco-tomy that mimicked aspergilloma," Annals of ThoracicSurgery 61 (May 1996) 1535-1536.

25. J S Dhillon, A Park, "Transmural migration of aretained laparotomy sponge," The American Surgeon 68Uuly 2002) 603-605.

26. R J Cruz et al, "Intracolonic obstruction induced bya retained surgical sponge after trauma laparotomy," (CaseReports) journal of Trauma 55 (November 2003) 989-991.

27. R S McLeod, J M Bohnen, "Canadian Associationof General Surgeons evidence based reviews in surgery9: Risk factors for retained foreign bodies after surgery,"Canadian journal of Surgery 47 (February 2004) 57-59.

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