Prevention of retained foreign objects, such as surgical sponges, during surgery has traditionally been accomplished by manually counting instruments used during the procedure. However, manual counting has been criticized as ineffective and leading to prolonged surgeries. This study used direct observation to address these questions, and revealed some limitations of the counting process, including the fact that discrepancies in the count were associated with changes in nursing personnel during the procedure. Nevertheless, intraoperative discrepancies were common enough that the authors strongly endorse adhering to traditional counting practices. A recent study evaluated using bar-coded surgical sponges as a potential method of increasing the accuracy of manual counting.