The Sponge Count That Was Off by One

In practice

The case is an open bowel resection. At the first layer of closure, the scrub person, Avery, and the circulating nurse count laparotomy pads aloud together, separating each one. The count is one short: the record shows twenty pads opened, and only nineteen can be accounted for. Avery says so at once, and the circulating nurse announces it to the surgeon, who stops closing. They recount from the beginning, at the field, then the Mayo stand, the back table and the counted, bagged pads. Still nineteen. The circulating nurse notifies the operating room supervisor, as policy requires. The surgeon examines the wound carefully, looking deep in the abdomen and under the edges of the incision. Meanwhile, the circulator checks the floor, the trash and the linen bag. Nothing is found. The surgeon asks for an X-ray before closing the skin. While they wait, the circulating nurse reviews the count sheet and notices that a second package of pads was opened in the middle of the case, during heavy bleeding, and added to the count by its printed number without being separated. Avery checks the opened package wrapper still on the back table: it held four, not five, so only nineteen pads ever reached the field. The X-ray shows no pad in the patient. The circulating nurse documents the discrepancy, the search, the X-ray, the reason for the difference, and the result. The wrapper is kept and reported, as the facility requires for incorrect packages.