Review Question - QID 213977

A 33-year-old male undergoes open reduction internal fixation of his right acetabulum fracture through a Stoppa approach. At one point in the case, brisk bleeding is encountered and the wound is packed. A shift change occurs for the scrub and circulating nurses shortly after the bleeding is controlled. The surgeons begin to close and during the closure, the sponge count was found to be one short. The closure was stopped, the wound was explored and no sponges were found. An intra-operative radiograph was taken and again no sponges were found. Finally, after 30 minutes the sponge was found hidden under instruments. What institutional change could be implemented to prevent this error and others in the future?