Importance of instrument count during surgical procedure

By Katherine A. Bubric, MSc

Surgical counting is the process of accounting for all surgical items before, during and at the conclusion of a surgical procedure to ensure that no items are left inside the patient. On the surface, surgical counting may look like a simple task. However, as all operating room nurses know, surgical counting is complicated, and errors can occur for several reasons.

Items are constantly moving. Sponges get saturated and stick together. Count sheets are not optimally designed. There can be hundreds of items to count. Needles are small. The operating room may be noisy. There are side conversations, interruptions and other team dynamics to consider. There is a patient in need of constant attention. The list goes on and on.

Errors in surgical counting can lead to an unintentionally retained surgical item, which is considered an unacceptable error because of the serious negative impact it can have on patient health and safety. It is widely accepted that this type of error is preventable given organizational checks and balances. Yet, at hospitals around the world, there are instances of surgical items being retained.

Human Factors Evaluation
Human factors is a discipline concerned with optimizing the fit between people and the systems they work in, and in preventing human error. Although humans are prone to error, environments and tools can be designed and modified so they are more resistant to errors.

To improve and standardize surgical counting practices across Alberta, the Alberta Health Services (AHS) Human Factors team completed a comprehensive evaluation of surgical counting practices and tools within the organization. Results of this evaluation included the:

1)development and implementation of a standardized provincial surgical count record
2)provision of more than 100 recommendations to standardize surgical counting practices, which were incorporated in a new provincial surgical count policy

Part of the evaluation included observing individuals performing surgical counts during surgical procedures. One of the goals of these observations was to identify positive counting practices to spread and potentially negative practices to avoid. A specific focus of the work was looking at the prevalence of interruptions and distractions during surgical counts, which are detailed in the September 2021 issue of The Joint Commission Journal on Quality and Patient Safety (JQPS).

Distractions were prevalent during surgical counting activities, particularly during the initial count, and came from a range of sources, including:

• ringing phones
• conversations
• music
• people entering and exiting the operating room 

Interruptions were most common during closure counts (e.g., surgeons asking the scrub nurse a question or for an item).

Preventing and Mitigating Effects of Interruptions and Distractions 
While both surgeons and nurses are concerned and responsible for the care of the patient, they have different priorities and are completing different tasks. There might not always be strong situational awareness of what other care team members are doing during surgery. For example, a scrub nurse could be pulled between two different activities – such as surgical counting and assisting the surgeon with the procedure. This inevitably results in multi-tasking and the potential for attention being pulled in different directions.

There are strategies that can help prevent interruptions and distractions – mitigating negative consequences, including:

• simulation training focused on teamwork and understanding of the operating room
• empowering nurses (e.g., in policy and through expectation setting) to vocalize when a count is about to occur and proactively asking the surgeon if anything is needed before starting
• providing standardized tools and processes that assist in interruption recovery
• using radio-frequency identification systems to improve count accuracy

AHS is currently in the process of implementing a standardized provincial surgical count policy and count record to improve counting practices across the province.

While surgical counting is a complex and high-risk task, the entire surgical team can work together to prevent unintentionally retained surgical items. Whether it is changing the OR culture, improving situation awareness, improving communication, introducing new practices, or standardizing the count process – together we can keep our patients safe.

Katherine A. Bubric, MSc, is a Human Factors Specialist at Alberta Health Services in Calgary, Alberta, Canada. Ms. Bubric’s research focuses on preventing human error and patient harm by improving the design of the health care system, including to the design of workspaces, information, processes, medications storage and labeling, and more. 

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