Using a Data-Matrix–Coded Sponge Counting System Across a Surgical Practice: Impact After 18 Months



      Retained surgical items (RSIs), most commonly sponges, are infrequent. Yet despite sponge-counting standards, failure to maintain an accurate count is a common error. To improve counting performance, technology solutions have been developed. A data-matrix–coded sponge (DMS) system was evaluated and implemented in a high-volume academic surgical practice at Mayo Clinic Rochester (MCR). The primary end point was prevention of sponge RSIs after 18 months.


      Two trials were conducted before implementation. A randomized-controlled trial assessed the system’s function, efficiency, and ergonomics. The second, larger trial was conducted to validate the prior findings and test product improvements. After the trials, the system was implemented in all 128 operating/procedure rooms across the MCR campus on February 2, 2009. The institutionwide implementation was intended to avoid the possibility of having standard unmarked sponges and DMSs in the operating room suite concurrently.


      Before implementation, a retained sponge occurred on average every 64 days. Between February 2009 and July 2010, 87,404 procedures were performed, and 1,862,373 DMSs were used without an RSI (p < .001). After four cases, the average time to count a DMS decreased from 11 to 4 seconds. Total sponge counting time/operation increased without any increase in overall operative time.


      After 18 months, a DMS system eliminated sponge RSIs from a high-volume surgical practice. The DMS system caused no work-flow disruption or increases in case duration. Staff satisfaction was acceptable, with a high degree of trust in the system. The DMS system is a reliable and cost-effective technology that improves patient safety.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Joint Commission Journal on Quality and Patient Safety
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Institute of Medicine
        To Err Is Human: Building a Safer Health System.
        National Academy Press, Washington, DC1999
        • National Quality Forum (NQF)
        Serious Reportable Events in Healthcare: A Consensus Report.
        NQF, Washington, DC2002
      1. Shetty R.: Towel Found in Dead Woman’s Body. Aug. 6, 2004. (last accessed Dec. 7, 2010).

        • Sowka M.P.
        Executive summary: The medical malpractice closed claims study.
        Conn Med. Feb. 1981; 45: 109-115
        • Gawande A.A.
        • et al.
        Risk factors for retained instruments and sponges after surgery.
        N Engl J Med. Jan. 16, 2003; 348: 229-235
        • Cima R.R.
        • et al.
        Incidence and characteristics of potential and actual retained foreign object events in surgical patients.
        J Am Coll Surg. Jul. 2008; 207 (Epub May 23, 2008): 80-87
        • Cima R.R.
        • et al.
        A multidisciplinary team approach to retained foreign objects.
        Jt Comm J Qual Patient Saf. Mar. 2009; 35: 123-132
        • Rogers A.
        • Jones E.
        • Oleynikov D.
        Radio frequency identification (RFID) applied to surgical sponges.
        Surg Endosc. Jul. 2007; 21 (Epub May 5, 2007): 1235-1237
        • Macario A.
        • Morris D.
        • Morris S.
        Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology.
        Arch Surg. Jul. 2006; 141: 659-662
        • Greenberg C.C.
        • et al.
        Bar-coding surgical sponges to improve safety: A randomized controlled trial.
        Ann Surg. Apr. 2008; 247: 612-616
        • Association of periOperative Registered Nurses (AORN): Recommended practices for sponge, sharp, and instrument counts
        Perioperative Standards and Recommended Practices.
        AORN, Inc, Denver2008: 293-302
        • González-Ojeda A.
        • et al.
        Retained foreign bodies following intraabdominal surgery.
        Hepatogastroenterology. Mar.–Apr. 1999; 46: 808-812
        • Hyslop J.W.
        • Maull K.I.
        Natural history of the retained surgical sponge.
        South Med J. Jun. 1982; 75: 657-660
        • Yildirim S.
        • et al.
        Retained surgical sponge (gossypiboma) after intraabdominal or retroperitoneal surgery: 14 cases treated at a single center.
        Langenbecks Arch Surg. Aug. 2006; 391 (Epub Sep. 17, 2005): 390-395
        • Lauwers P.R.
        • Van Hee R.H.
        Intraperitoneal gossypibomas: The need to count sponges.
        World J Surg. May 2000; 24: 521-527
        • Yeung K.W.
        • Chang M.S.
        • Huang J.F.
        Imaging of transmural migration of a retained surgical sponge: A case report.
        Kaohsiung J Med Sci. Nov. 2004; 20: 567-571
        • Christian C.K.
        • et al.
        A prospective study of patient safety in the operating room.
        Surgery. Feb. 2006; 139: 159-173
        • Anderson S.
        • Wittwer W.
        Using bar-code point-of-care technology for patient safety.
        J Healthc Qual. Nov.–Dec. 2004; 26: 5-11
        • Cochran G.L.
        • et al.
        Errors prevented by and associated with bar-code medication administration systems.
        Jt Comm J Qual Patient Saf. May 2007; 33: 293-301
        • Regenbogen S.E.
        • et al.
        Prevention of retained surgical sponges: A decision-analytic model predicting relative cost-effectiveness.
        Surgery. May 2009; 145 (Epub Mar. 21, 2009): 527-535
        • Kaiser C.W.
        • et al.
        The retained surgical sponge.
        Ann Surg. Jul. 1996; 224: 79-84
      2. Centers for Medicare & Medicaid Services (CMS): Fact Sheet: CMS Improves Patient Safety for Medicare and Medicaid by Addressing Never Events. (last accessed Dec. 7, 2010).

        • Dossett L.A.
        • et al.
        Cost-effectiveness of routine radiographs after emergent open cavity operations.
        Surgery. Aug. 2008; 144 (Epub Jun. 5, 2008): 317-321
        • Lincourt A.E.
        • et al.
        Retained foreign bodies after surgery.
        J Surg Res. Apr. 2007; 138 (Epub Feb. 1, 2007): 170-174