Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis.
Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):132-41. doi:10.1016/j.aorn.2010.09.034.
A prospective failure mode and effect analysis identified 57 potential failures that each could lead to a retained surgical instrument. Most of these potential failures require technological rather than educational or policy-based solutions.