After having never ‘lost’ a mitomycin soaked sponge behind an eye in 16 years of performing this procedure, I recently had this happen twice. The first time, I thought that I should find a better way to prevent this and sought suggestions from colleagues and also reassurance that this has happened to them. The second time this happened, just a couple of weeks later, I implemented a change that two O.R. nurses thought of…the mini-neuropatties. This article shows video footage of losing a sponge along with the solution of using mini-neuropatties instead of pieces of instrument wipes. I also discuss why this is more likely to happen now than in earlier years.

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