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Table 3 Contributing Factors to Retained Surgical Sponges

From: Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017

Human Factors (n = 417)  
 Medical staff peer review/credentialing 126
 Staff orientation/in-service education 94
 Competency assessment 49
 Staff supervision 13
 Resident supervision 9
 Staffing levels/skill mix 6
 Other human factor issues 120
Leadership (n = 394)
 Compliance with policies & procedures 205
 Policies & procedures 129
 Organizational culture 31
 Directing departments/services 11
 Nursing leadership 3
 Medical staff - Other 3
 Other leadership issues 12
Communication (n = 330)
 With physician 153
 Among staff 92
 Oral communication 54
 Written/electronic communication 14
 With administration 13
 Other communication issues 4
Operative Care (n = 108)
 Other operative care issues 69
 Operative care planning 37
 Other 2
Assessment (n = 82)  
 Adequacy of assessment 56
 Patient observation 19
 Scope or timing of reassessment 4
 Care decisions 3
Physical Environment (n = 33)
 Equipment management 22
 Emergency management 2
 Other environmental issues 9
Information Management (n = 25)
 Technical systems 10
 Availability of information 8
 Medical records 6
 Patient identification 1
Performance Improvement (n = 21)
 Data collection 12
 Other PI issues 9
Other 20
Grand Totala 1430
  1. aNo root cause was identified in 1 event report