counting instruments and sponges

AUGUST 2003, VOL 78, NO 2 Patient Safety First

P A T I E N T S A F E T Y F I R S T

Counting I i n s t rumen t s and sponges

he origins and purposes of counting instruments and sponges are unclear, but it appears that counting first T started as an effort to address

lost marine sponges in the early days of surgical nursing. By the beginning of the 20th century, nurses were instructed to count sponges routinely before surgery and before closure. A 1901 article on nursing addresses counting sponges, but counting instruments is not mentioned.'

Most experts agree that systematic counting of instruments evolved after the routine practice of counting sponges already was established. This may have occurred in part because of an increased loss of instruments that coincided with the widespread adop- tion of disposable drapes in 0%. Some nurses may recall that increased costs from the loss of surgical instruments inadvertently discarded with disposable drapes resulted in establishment of formal counting processes. It was not until 1976, however, that AORN first published standards for sponge, needle, and instrument counts?

CONCERNS ABOUT COUNTING Many perioperative nurses now are

questioning the efficacy of counting surgical instruments and sponges for every procedure. Some nurses have voiced concerns that the culture in their clinical setting places a higher priority on efficiency and decreasing turnover times than on counting. Some nurses mention that addressing unresolved counts with certain practitioners can be problematic, and others say time pres- sures and instrument complexity contribute to errors that occur during sur-

AORN's "Recommended practices gical counts.

for sponge, sharp, and instrument

counts" is based on the legal premise that leaving a foreign object in a patient is considered negligence? AORN rec- ommends that health care team members collaborate to establish and imple- ment policies and procedures related to counts in individual practice settings. AORN's recommended practices address what should be counted for which types of procedures, how counts should be performed, and who should perform counts.

To incorporate these standards and address concerns about retained foreign bodies, most clinical settings have devel- oped policies and procedures related to counts. Despite efforts to ensure safety, however, stories about retained instruments persist. Many perioperative nurses can relate stories about near misses or actual adverse events related to counts. Despite the count sheet being correct, many patients later are found to have retained an instrument or sponge. Reasons for these medical errors remain unclear, but sponge, sharp, and instrument

Counting is an emr-prone

process that can result in pain and

further surgery for the patient and higher costs

for patients, clinicians, and

health care systems.

counting remains an error-prone process that often results in pain, dis- ability, and another surgical procedure for patients. These errors also result in costs to the affected patients, clinicians, and health care systems.

AN ERROR-PRONE PROCESS Donald Church's story provides an

example of the pain and suffering associated with a retained surgical

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instrument. Church had an abdominal procedure to remove a malignant tumor. After the procedure, he expe- rienced weeks of pain and suffering. A computed tomography scan eventually revealed a 13-inch malleable retractor that was left inside of him: Although widely reported, this incident is only one of many that are reported in the media. Another incident of a retained 14-inch retractor involved a health care facility that then had another retained item incident within one year.5 Most perioperative nurses would agree, however, that these specific types of retractors rarely, if ever, are counted.

ronment, surgical counts appear to serve three basic purposes: inventory control, staff member and student education, and patient safety. Most clinicians in the OR, however, are not entirely clear about why they are counting in a particular situation. Counts often are performed because they are part of a habitual, routine process. In addition, the standards for counting often are unclear to other practitioners. Clinicians who never have left a foreign object in a wound also may downplay the risks.

The literature related to human errors describes error- prone processes and the inherent challenge of perfom- ing routine tasks when preoc- cupied or distracted! Counting instruments provides a model for such a rou-

In today's health care envi-

tine task in the OR. Character- istics that contribute to the error-prone nature of counting include that counting often is highly automatic and prone to unexpected intermp- tions and that clinicians move to a different task before com-

Today, surgical counts seem to serve

three purposes, including inventory

control, staff member education, and patient safe@, but many clinicians are uncertain about

why they are counting in a given

situation.

pleting final validation that the count is correct! In other words, counts provide an ideal opportunity for errors to occur, and preventing retained instruments is not as simple as counting correctly. This finding is verified in the initial reports to Safety Net, AORN's near miss reporting database. A common theme of distraction occurred in several of the stories. For example, documentation errors

occurred because of intemp- tions and cultural norms. Risk factors identified in this limit- ed sample include

nuries needing to leave the room to obtain supplies when sponges were added to the field, excessive talking during counts, sponges placed in cavities for packing during the case, and nurses signing for counts that were not performed. Common sense probably

was the primary reison OR personnel began counting. It was a simple remedy to concerns about leaving sponges in a body cavity, losing costly instruments, educating nurses, or keeping track of numer- ous types and sizes of nee- dles. When counting practices first were established, however, the OR environment was much different than it is today. Not only has the instm- mentation and technology become much more complex, but procedws also have become more sophisticated and complicated. Despite this, no new technology or strategy has emerged to help clinicians ascertain the accuracy of their counts or perform them with more consistency, accuracy, or efficiency.

RESEARCH RELATED TO COUNTING Recent research describes

the clinical conditions and situations that may contribute to retained sponges and instruments. A recently reported, case-controlled, retrospective analysis of retained foreign

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AUGUST 2003, VOL 78, NO 2 Patient Safety First

bodies in surgical patients identifies a number of risk factors. Researchers found that the risk of retention sig- nificantly increases in emer- gency surgeries, in surgeries that include unplanned procedures, and in patients with a higher body-mass index? Most perioperative nurses are not surprised by these findings and previously may have expressed concerns that these types of procedures or situations are among the most challenging and risky for performing accurate counts.

Based on their findings, the researchers suggest several strategies to reduce the risk of retained instruments, sharps, and sponges, including monitoring compliance with existing standards related to counting sponges in every surgical procedure and counting instruments in open procedures. The researchers also report that for cases of retained foreign objects in which a count was performed, the count sheet indi- cated that the count was correct in 88% of cases; there- fore, they suggest using routine intraoperative radi- ographic screening of patients undergoing procedures that place them at high risk of retaining instrument^.^

Reports such as this con- firm perioperative nurses’ concerns about performing accurate counts, but the challenge of performing accurate counts persists. One can only hope that an easy-to-use tech-

nological innovation for performing counts will be devel- oped. In the meantime, what should nurses do?

First, review the policies and procedures in your facility. Consider whether they are up-to-date and reflective of the needs of patients undergoing surgery. For example, are surgeons performing more procedures on patients who are obese or emergent? If so, are safeguards in place? Engage other nurses and clinicians in a discussion about policies and procedures and the purpose of performing counts in specific situations, and review the latest research on the topic. The purposes for counting should be clear to all health care providers in a surgical suite. If the goal is to prevent a retained foreign body, everyone should be committed to a process that ensures the count is correct. In certain instances, this may require ordering an x-ray or taking more time to resolve a discrepancy.

CONCLUSION Nurses need to collaborate

with members of the health care team to establish mean- ingful policies and procedures related to counting. Team members must be committed to the same outcome (ie, no retained foreign objects). To achieve this goal, team members must establish best practice protocols to ensure patient safety related to counts. These protocols

must be implemented in a consistent manner and con- tinually evaluated. Learning about safety is a continual process. Learn from actual errors as well as from any near misses, and remember, patient safety is about improving systems and processes. 9

SUZANNE C. BEYEA RN, PHD, FAAN

DARTMOUTH-HITCHCOCK MEDICAL CENTER LEBANON, NH

DIRECTOR OF NURSING RESEARCH

NOTES 1. M Luce, ”The duties of an operatin -room nurse,” American Journal ofNursing 1 no 6 (1901) 404-406,471-473. 2. “Standards for sponge, needle, and instrument procedures,” AORN Journal 23 (May 1976) 971- 973. 3. ”Recommended practices for sponge, sharp, and instrument counts“ in Standards, Recommended Practices, and Guidelines (Denver:

4. W King, ”UW settles suit over tool left in patient,” The Seattle Times (4 Dec 2001), http://archi ves.seattletimes.nwsource.com /c i-binltexis .cgi/web/vortex /Jsplay. 3 s lug=malpractice04m0&da te=20011204&quwy=U W+settles+s uit+over+tool+l@+in+patient (accessed 25 June 2003). 5. C Clark, ”Hospital is investi- ated anew; Palomar Medical

Eenter forgot sponge in patient, year after similar incident,” The San Diego Union-Tribune, 1 Dec

6. J T Reason, Human Error (New York Cambridge University Press, 1990). 7. A A Gawande et al, “Risk factors for retained instruments and

AORN, I ~ c , 2003) 221-226.

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