Unused white surgical sponges are hard to miss – until they turn red and conform to patient anatomy. An unreconciled count can easily be acted on per hospital protocol. But “false correct counts” – when numbers match and are perceived as correct, but aren’t – go undetected. This hidden danger prevents real-time corrective action and unintentionally increases the risk for all parties.
“Most errors in healthcare are due to human factors. It’s like aviation – if you don’t do these checks, there can be human errors that happen.”28
“Counting is a human process that’s very prone to error, especially in a busy environment where multiple things are happening simultaneously.”9
“Gawande et al. noted that in 88% of cases…the final count was erroneously believed to be correct. This implies a dual error: leaving an item in the patient, and a counterbalancing miscount that results in a false ‘correct’ count.”27
“The surgical tech attempted to recount 3 sponges that had already been counted. The barcode system alerted her to the duplication and avoided a potential error in the count.”19