The real truth about false correct counts
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.“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
Caprice C. Greenberg, M.D., M.P.H, Brigham and Women’s Hospital
“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
Valerie Marsh, RN, MSN, University of Michigan Health System
“Counting is a human process that’s very prone to error, especially in a busy environment where multiple things are happening simultaneously.”9
Gail Horvath, MSN, RN, CNOR, CRCST Patient Safety Analyst, ECRI Institute
“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
WHO Guidelines for Safe Surgery
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9100-003-611 Rev None