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Summary: During any surgical operation, there is an inherent "duty" owed to the patient that the operation will be carried out competently. This includes carrying out specified procedures and taking measures to prevent "foreign" objects from being left in the body cavity. In this case, during a coronary artery bypass grafting, a clamp slipped from the surgeon's sight. It would be found on x-ray later sitting behind the patient's heart. The patient was admitted for a routine coronary artery bypass grafting procedure. "What is coronary artery bypass surgery? A coronary artery bypass graft operation is a type of heart surgery. It is sometimes referred to as CABG or "cabbage." The surgery is done to reroute, or "bypass," blood around clogged arteries and improve the supply of blood and oxygen to the heart. These arteries are often clogged by the buildup over time of fat, cholesterol and other substances. The narrowing of these arteries is called atherosclerosis. It slows or stops the flow of blood through the heart's blood vessels and can lead to a heart attack."2 In the operating room, the procedure was carried out and per protocol, it was documented that all sponges and needles were accounted for by the nurses and physician. What was not accounted for and not "picked up" on until later was a clamp used during the procedure. Following a routine chest x-ray post-op, the clamp would be discovered resting in the pericardial sac, behind the patient's heart. At that time, no hospital protocol existed mandating "counts" on instruments during procedures (only sponges). "Materials counts are necessary to provide a standard of quality of care for the surgical patient and to provide a method of accounting for items placed on the sterile field for use on a surgical procedure."3 The