After an emergency surgery, a nurse counts all the supplies and notices that a sponge is missing. The surgeon asks the nurse if she removed the sponge, and she replies that she thinks the surgeon removed it. Nobody on the team can account for the missing sponge. What best describes this scenario?

The team cannot account for a missing sponge after surgery, and the nurse and surgeon are unsure who removed it. This shows a breakdown in communication and coordination, creating an unsafe, undesirable outcome. The best choice is “an undesirable outcome caused by poor teamwork.”

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