What's Your Count?

Stryker Ipad device used to scan sponges in/out used in the perioperative setting

Importance of Surgical Counts

As a perioperative nurse, I take the surgical count process very seriously. Retained surgical items (RSI) are the most common category of surgical never events (Carmack, et al., 2024). A never event is an event that causes serious, preventable and costly medical errors that should never happen. It is estimated that 1 out of 1,000 to 18,000 procedures per year have a RSI reported (Weprin, et al., 2021). However, it is thought the numbers are often under-reported. The negative impact of RSI's obviously affects the patient, but the physician, staff, and hospital facility face serious consequences as well.

Count in the Perioperative Setting

Counts include sponges, sharps (needles, blades, sutures), and instruments. Counts should be performed prior to the patient entering the operating room. Both the scrub tech in charge of the back table and the RN Circulator should keep their eyes on the items counted. The count is usually recorded on a whiteboard or "count sheet." Once the procedure starts, as items are added to the field, the circulator will adjust the count on the whiteboard to reflect the correct count so the scrub team can see and be aware of the count as it changes. When the surgeon begins to close the surgical site, a sponge and sharp count is obtained. When indicated, an instrument count is obtained (larger abdominal cases). The last sponge and sharp count is performed when the surgeon begins to close the skin. Both the scrub tech and RN circulator should visualize the counted items, never assume. If the count is incorrect at any time, the surgeon is notified, the team stops, and searches for the missed item. If the item is not found, an x-ray should be taken to confirm that the item is not in the patient. The patient should be kept asleep until the x-ray is read and confirmed negative. If the item is observed in the xray, the surgeon will open the surgical site and remove the sponge and thus prevent a RSI and never event in the perioperative setting.

Preventive Measures to Reduce RSI's

Communication is key to achieving a correct count. It is important to communicate any changes in the count during the case. When the surgical case changes staff, such as lunch breaks, the count should be visualized and communicated with the oncoming staff. Sponges also have barcodes on the packs that match each sponge. The barcode on the pack of sponges is scanned at the start of the case. When the case is over, the individual sponges are scanned, and a confirmation is given that all sponges have been scanned out. If a sponge is missing, it will be recognized at this point. The case is stopped, and efforts are made to find the missing sponge until it is found.

Conclusion

We are our patients' biggest advocate in the perioperative setting. Communication failures occurring between surgical teams, surgeons, and OR staff play a factor in leading to a high risk of RSI. Other factors noted that lead to increased risk of RSI include distractibility and lack of adaptability among the OR team (Weprin, et al., 2021). Practicing vigilence, compliance, and communication in the operating room is key to ensuring that all counts are correct and patients are safe.

References:

Carmack, A., Randall, K., & Valleru, J. (2024, May 29). Reducing preventable patient harm due to retained surgical items: The RSI Bundle. Patient Safety Network. https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle

Weprin S, Crocerossa F, Meyer D, Maddra K, Valancy D, Osardu R, Kang HS, Moore RH, Carbonara U, J Kim F, Autorino R. Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review. Patient Saf Surg. 2021 Jul 12;15(1):24. doi: 10.1186/s13037-021-00297-3. PMID: 34253246; PMCID: PMC8276389.

Assessed and Endorsed by the MedReport Medical Review Board