Which sponges should be counted first during the final count as according to the surgical count policy?

DENVER -- The following proposed recommended practice for sponge, sharp, and instrument counts was developed by the Association of periOperative Registered Nurses (AORN) Recommended Practices Committee. It is being presented for review and comment at this time. The AORN Recommended Practices Committee is interested in receiving comments on this proposal from members and others.

These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be implemented.

AORN recognizes the numerous settings in which perioperative nurses practice. These recommended practices are intended as guidelines that are adaptable to various practice settings. These practice settings include traditional ORs, ambulatory surgery centers, physicians offices, cardiac catheterization suites, endoscopy suites, radiology departments, and all other areas where operative and other invasive procedures may be performed.

Purpose

These recommended practices provide guidance to perioperative nurses in performing sponge, sharp, and instrument counts in their practice settings. Counts are performed to account for all items and to lessen the potential for injury to the patient as a result of a retained foreign body. Complete and accurate counting procedures help promote optimal perioperative patient outcomes and demonstrate the perioperative practitioners commitment to patient safety.

 Legislation does not prescribe how counts should be performed, who should perform them, or even that they need to be performed. The law only requires that foreign bodies not be negligently left in patients. 1 The doctrine of res ipsa loquitur (ie, the thing speaks for itself) is most applicable in cases involving retained foreign objects, rendering those litigations nearly indefensible. 1, 2 Retained objects are considered a preventable occurrence, and careful counting and documentation can significantly reduce, if not eliminate, these incidents. 3, 4 The captain of the ship doctrine is no longer assumed to be true, and members of the entire surgical team can be held liable in litigation for retained foreign bodies. 5-10 All team members should be committed to and involved in establishing meaningful policies and procedures related to surgical counts. 11, 12

The perioperative nursing vocabulary is a clinically relevant and empirically validated standardized language. This standardized language consists of the Perioperative Nursing Data Set ( PNDS) and includes perioperative nursing diagnoses, interventions, and outcomes. The expected outcome relevant to this recommended practice is to ensure that the patient is free from injury related to retained sponges, instruments, and sharps, 13 (88) which is found within Outcome O2, The patient is free from signs and symptoms of injury due to extraneous objects. 13 (85)

The following recommended practices are considered established guidelines for perioperative practice.

Recommended Practice I

Sponges should be counted on all procedures in which the possibility exists that a sponge could be retained.

Sponge counts should be performed:

-- before the procedure to establish a baseline,

-- before closure of a cavity within a cavity,

-- before wound closure begins,

-- at skin closure or end of procedure, and

-- at the time of permanent relief of either the scrub person or the circulating nurse.

Initial sponge counts should be performed and recorded on all procedures, as they establish a baseline for subsequent counts. Established policies in the facility may define when additional counts must be performed or may be deleted (eg, cystoscopy, ophthalmology). 14, 15 Accurately accounting for sponges throughout a surgical procedure is a primary responsibility of the perioperative nurse and constitutes a proactive injury-prevention strategy. 2, 3, 16-18 Closed claim studies conducted during the past 20 years have demonstrated that roughly two-thirds of reported retained surgical object cases are attributed to sponges. 4, 19-21 Although the majority of retained sponges are found in the abdomen and pelvis, there are reports in the literature discussing retained sponges in the vagina, thorax, spinal canal, face, brain, and extremities. 4, 22-28

2. Sponges should be separated, counted audibly, and concurrently viewed during the count procedure by two individuals, one of whom should be a registered nurse circulator. 3, 18, 29 Concurrent verification of counts by two individuals lessens the risk of inaccurate counts. Separating sponges during the baseline count helps to determine whether a sponge has been added to or deleted from a sterilized package. 1, 3, 18, 30 Use of a pocketed bag or other system for separating used sponges may facilitate visualization for counting. Separating sponges after use minimizes errors caused by sponges sticking together.

3. When additional sponges are added to the field, they should be counted at that time and recorded as part of the count documentation to keep the count current and accurate. 3

Perioperative personnel should count all prepackaged sterilized sponges for accuracy. Any package containing an incorrect number of sponges should be removed from the field, bagged, labeled, and isolated from the rest of the sponges in the OR. Containing and isolating the entire package helps reduce the potential for error in subsequent counts. 18

Sponge counts should be conducted in the same sequence each time as defined by the facility. The counting sequence should be in a logical progression, (eg, from large to small or from proximal to distal). A standardized count procedure, following the same sequence, assists in achieving accuracy, efficiency, and continuity among perioperative team members. 31 Studies in human error have shown that all errors involve some kind of deviation from routine practice. 32 (57)

All sponges used during a surgical procedure should be x-ray detectable. Radiopaque indicators facilitate locating an item presumed lost or left in the surgical field when a count discrepancy occurs. X-ray detectable sponges should not be used as dressings. The use of x-ray-detectable sponges as surface dressings may invalidate subsequent counts if the patient is returned to the OR. X-ray-detectable sponges used as dressings may appear as foreign bodies on postoperative x-ray studies. 30, 33-35

Towels without radiopaque markers should not be used in the wound. If towels are used in the open wound, they should be included in the count as a miscellaneous item, and should be easily distinguishable from other towels on the sterile field.

Sponges should be left in their original configuration and should not be cut. Altering a sponge invalidates subsequent counts and increases the risk of a portion being retained in the wound. 17, 23

Nonradiopaque gauze dressing materials should be withheld from the field until the wound is closed or the case is completed. Keeping dressing materials separated from the actual counted sponges will help prevent intermingling with the sponges used in the procedure. 3

All counted sponges should remain within the OR or sterile field during the procedure. Linen and waste containers should not be removed from the room until counts are completed and resolved. Confinement of all counted sponges to the OR helps eliminate the possibility of an incorrect count. 18

Counted sponges should not be used as postoperative packing; however, when counted sponges are intentionally used as packing and the patient leaves the OR with this packing in place (eg, damage control procedures), the number and type of sponges retained and reason for the variation should be documented on the intraoperative record as correct and confirmed by the surgeon. 3, 15,36 When the packed sponges are removed, the number and type should be recorded in the patients record.

Sponges should be removed from the OR at the end of the procedure. Removing sponges from the OR at the end of the procedure helps prevent potential incorrect counts on subsequent procedures. 18

Contaminated sponges must be handled and disposed of according to Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Final Rule; AORNs Recommended practices for environmental cleaning in the surgical practice setting, and Recommended practices for standard and transmission-based precautions; and facility policies and procedures. The use of leak proof, tear-resistant containers and personal protective equipment (PPE) can help prevent environmental contamination and reduce the risk of personnel exposure to potentially infectious material. 37-39

 Recommended Practice II

 Sharps and other miscellaneous items should be counted on all procedures.

Sharps and miscellaneous item counts should be done

-- before the procedure to establish a baseline,

-- before closure of a cavity within a cavity,

-- before wound closure begins,

-- at skin closure or end of procedure, and

-- at the time of permanent relief of the scrub person and/or circulating nurse.

Initial sharps counts should be performed and recorded on all procedures. Performing counts constitutes a primary and proactive injury-prevention strategy. 1 Counting sharps and miscellaneous items is not only important in preventing foreign body retention; the continuous accounting for these items can lessen injuries to those scrubbed in the sterile field. Data have shown that 78 percent of reported needlestick exposures are to surgeons and scrubbed personnel in the OR. 40

Sharps and miscellaneous items should be counted audibly and viewed concurrently by two individuals, one of whom should be a registered nurse circulator. Concurrent verification of counts by two individuals lessens the risk for inaccurate counts. 1

Accurately accounting for sharps during a surgical procedure is a primary responsibility of the perioperative nurse and the surgical team members. Additional sharps and miscellaneous items added to the field, should be counted when added and recorded as part of the count documentation.

Suture needles should be counted and recorded according to the number marked on the outer package and verified by the scrub person when the package is opened. Opening all packages during the initial needle count is not recommended and would result in needles being exposed during the entire surgical procedure. This creates an additional opportunity for lost or retained needles during the procedure. 41

The scrub person should be able to account for all sharps on the sterile field. Sharps remaining unconfined on the sterile field may be unintentionally introduced into the incision or dropped on the floor or may penetrate barriers.

Whenever possible, sharps must be handed to and from the surgeon on an exchange basis using a neutral zone or hands free technique. 38, 42 Passing sharps to the surgeon on an exchange basis will lessen the possibility of a lost sharp item. 43

Sharps counts should be conducted in the same sequence each time as defined by the facility. The counting sequence should be in a logical progression (eg, from large to small item size or from proximal to distal from the wound). A standardized count procedure, following the same sequence, assists in achieving accuracy, efficiency, and continuity among perioperative team members. 31 Studies in human error have shown that all errors involve some kind of deviation from routine practice. 32 (57)

Members of the surgical team should account for sharps or other miscellaneous items that may have been broken or become separated within the confines of the surgical site in their entirety. Breakage and/or separation of parts can occur during open as well as minimally invasive surgical procedures. Verification that all broken parts are present or accounted for helps prevent unintentional retention of a foreign body within the patient. 15, 44-46

Used sharps on the sterile field should be kept in a disposable, puncture-resistant container. Collecting used needles in a container helps ensure their containment on the sterile field and lessens the risk of injury to personnel at the sterile field. 37,38 Disposing of sharps in designated sharps containers helps lessen the potential for personnel injury and/or exposure to potentially infectious material. 39 Accounting for and disposing of all sharps and related items at end-of-procedure cleanup helps avoid potential incorrect counts on subsequent procedures.

All counted sharps should remain within the OR and/or sterile field during the procedure. If a sharp is passed or dropped off the sterile field, the circulating nurse should retrieve it in a safe manner, show it to the scrub person, and isolate it from the field to be included in the final count. Linen or waste containers should not be removed from the OR until all counts are completed and resolved and the patient has been taken from the room. Confinement of all sharps to the OR helps minimize the possibility of an incorrect count. 18

Sharps must be handled according to OSHA Bloodborne Pathogen Standards. Proper use, handling, and disposal of contaminated sharps helps minimize the risk of exposure to bloodborne pathogens from patient to health care worker and from health care worker to patient. 39 Additional information can be found in AORNs Recommended practices for standard and transmission-based precautions in the perioperative practice setting. 38 Sharps should be disposed of according to AORNs Recommended practices for environmental cleaning in the surgical practice setting. 37

Recommended Practice III

 Instruments should be counted for all procedures in which the likelihood exists that an instrument could be retained.

1. Instrument counts should be performed

-- before the procedure to establish a baseline,

-- before wound closure, and

--when feasible, at the time of permanent relief of the scrub person and/or circulating nurse

Instrument counts protect the patient by reducing the likelihood that an instrument will be retained in the patient. Instrument counts are a proactive injury-prevention strategy. 1 Retention of surgical instruments accounts for approximately one third of retained item case reports. 4 Case studies demonstrate that many types and sizes of instruments have been found, ranging from small serrifine clamps to moderately-sized hemostats (ie, six to 10 inches) to 13-inch long retractors. 48, 49

Instruments should be counted when sets are assembled for sterilization. This assembly count provides a basic reference for the instrument set and is not to be considered the initial count before the surgical procedure. A count performed outside the OR that is considered an initial count increases the number of variables that can contribute to an inaccurate count and unnecessarily extends responsibility to personnel not involved in direct patient care. 33

Initial counts in the OR establish a baseline for subsequent counts, particularly with the increase in minimally invasive surgery and the potential for additional procedures. The possibility of any incision being extended to allow for a more extensive procedure than anticipated supports the practice of performing an initial count for all procedures. Established policies in the facility may define when additional counts should be performed or may be deleted from procedures according to the likelihood of an instrument being retained.

Individual pieces of assembled instruments (eg, suction tips, wing nuts, blades, sheathes) should be accounted for separately on the count sheet. Removable instrument parts can be purposefully removed or become loose and fall into the wound or onto or off the sterile field. 46

When additional instruments are added to the field, they should be counted when added and recorded as part of the count documentation.

Instruments should be counted audibly and viewed concurrently by two individuals, one of whom should be a registered nurse circulator. Concurrent verification of counts by two individuals assists in ensuring accurate counts 1

Members of the surgical team should account for instruments that may have been broken or become separated within the confines of the surgical site in their entirety. Breakage and/or separation of parts can occur during open as well as minimally invasive surgical procedures. Verification that all broken parts are present or accounted for helps prevent unintentional retention of a foreign body within the patient. 15, 44-46

Instrument counts should be conducted in the same sequence each time as defined by the facility. The counting sequence should be in a logical progression (eg, from large to small item size or from proximal to distal from the wound). A standardized count procedure, following the same sequence, assists in achieving accuracy, efficiency, and continuity among perioperative team members. 31 Studies in human error have shown that all errors involve some kind of deviation from routine practice. 32 (57)

 All counted instruments should remain within the OR during the procedure until all counts are completed and resolved. If a counted instrument is passed or inadvertently dropped off the sterile field, the circulating nurse should retrieve it, show it to the scrub person, and isolate it from the field to be included in the final count. 39 Confinement of all counted instruments to the OR helps eliminate the possibility of an incorrect count. 41

All instruments should be accounted for and removed from the room during end-of-procedure cleanup. Accounting for all instruments facilitates inventory control and patient safety. Removing all instruments from the room helps avoid potential incorrect counts on subsequent procedures. 12

Instrument sets should be standardized with the minimum types and numbers of instruments needed for the procedure. Instruments that are not routinely used on procedures should be deleted from sets. Reducing the number and types of instruments and streamlining standardized sets improves ease and efficiency of counting. 30 Specialty instruments, if needed, can be opened and added to the count at the time of the procedure. 31

13. Preprinted count sheets that are identical to the standardized sets should be used to record the counted items. Preprinted count sheets provide organization and efficiency, which are key to preventing unnecessary delays. 3 The circulating nurse should record only the number of instruments opened for the procedure. Additional instruments requested by the surgeon should be counted and added to the preprinted count sheet separately. 15

14. Contaminated instruments must be handled according to OSHA Bloodborne Pathogen Standards. Proper use and handling of contaminated instruments help minimize the risk of exposure to bloodborne pathogens from patient to health care worker and from health care worker to patient. 39 Contaminated instruments should be handled according to AORNs Recommended practices for cleaning and caring for surgical instruments and powered equipment, 50 and Recommended practices for cleaning and processing endoscopes and endoscope accessories, 51 as well as the institutions policies and procedures. 46 Contaminated instruments may expose personnel to harmful pathogens. 47

Recommended Practice IV

Additional measures for investigation, reconciliation, documentation, and prevention of incorrect surgical counts should be taken.

1. When a discrepancy in the count(s) is identified, the surgical team is responsible for carrying out steps to locate the missing item. 3, 13, 46, 52

Procedural steps include, but are not limited to,

count discrepancy reported to surgeon;

procedure suspended, if patients condition permits;

manual inspection of the operative site;

visual inspection of the area surrounding the surgical field, including floor, kick buckets, and linen and trash receptacles;

intraoperative x-ray taken and read before patient leaves the OR, if the patients condition permits;

documentation of all measures taken on patients record;

reporting of incident (occurrence) following facility policy; and

review of incident or near miss for cause, effect, and prevention.

2. The circulating registered nurse should inform and receive an acknowledgment from the surgeon as soon as it is known that any part of the surgical count (ie, sponge, sharp, instrument) is incorrect. 2, 3, 15, 29, 52

3.The perioperative registered nurse circulator and scrubbed person should ask the surgeon to conduct a manual search of the wound to locate the missing item(s). The scrubbed person and circulator should do a manual and visual search, respectively, of the sterile area surrounding the wound and the remainder of the sterile field. The circulator should conduct a search of the nonsterile areas of the room in an attempt to locate the item(s). 2, 19, 21, 46, 52

4.If the item is not recovered, an intraoperative x-ray should be taken and read prior to the final closure of the wound. The purpose of the x-ray should be specified to rule out retained foreign body (eg, needle, sponge, instrument). Studies show greater accuracy when x-rays are read by a radiologist. 3,4,12,15,21,34,46,52 In the case of missing needles, there is no definitive evidence as to how effective x-rays are in detecting small suture needles. Studies done in recent years have demonstrated that needles 17 mm and smaller may not be consistently visible on x-ray. 53,54

5.Following institutional policy, documentation of an incorrect count should include all the measures taken to recover the missing item and communications made regarding the outcome. This is considered a sound professional practice and demonstrates that all reasonable efforts were made to protect the patients safety. 1,3,18,35,49

6. A critical investigation 18 (157) should be conducted of any patient safety incident process. Error and near miss reporting are the first steps to addressing error reduction. 55, 56 The distraction-prone environment of the OR means that performing routine tasks, such as surgical counts, can be considered at risk for error. 12 Errors can be divided into two categories, those at the human interface in a complex system (ie, active) and those representing failed system design (ie, latent). 57 Elements of the root cause analysis tool should to be considered in addressing the contributing causes (eg, human, process, system), identification of risks and preventative measures. 58 Staff and management should be involved in the process of review and address any changes in policy that can improve patient safety. 18

Additional measures should be established to minimize the risk of inaccurate counts during situations that are at higher risk for retained foreign bodies. Facilities should identify conditions or situations that pose an increased risk for retained foreign bodies. Risk factors may include, but are not limited to,

the emergent nature of a procedure,

an unexpected change in the procedure,

complicated procedures with multiple sets,

multiple procedures,

multiple teams, and

patient obesity. 4

Facilities also should review internal data from adverse events and near misses to identify high-risk situations within the facility. Facilities should establish measures to be taken, in addition to a count, for identified high-risk situations. These measures should include an intraoperative x-ray for foreign body. In one study, three of 29 x-rays were read as negative when a foreign body actually was present 19. Therefore, x-ray alone may be insufficient to detect a retained item.

Recommended Practice V

Sponge, sharp, and instrument counts should be documented on the patients intraoperative record.

Documentation of counts should include, but not be limited to,

types of counts (ie, sponges, sharps, instruments, miscellaneous items) and number of counts;

names and titles of personnel performing the counts;

results of surgical item counts;

notification of the surgeon;

instruments intentionally remaining with the patient or sponges intentionally retained as packing;

actions taken if count discrepancies occur; and

rationale if counts are not performed or completed as prescribed by policy.

Accurate documentation serves several purposes, including evidence of the patients treatment, the basis of the plan of care, communication to all caregivers, protection from liability, and a link to reimbursement. 35,59 Documentation of nursing activities related to the patients perioperative care provides an accurate picture of the nursing care administered and provides a mechanism for comparing actual versus expected outcomes. 60

Justification for omission of counts in an emergency should be documented. Extreme patient emergencies may necessitate omission of counts to preserve patient life or limb. Documenting the omission and reasons for the variation provides a record of the occurrence, and an alert to subsequent caregivers that the patient may be at an increased risk for a retained foreign body. 3

Recommended Practice VI

Policies and procedures for sponge, sharp, and instrument counts should be developed, reviewed annually, revised as necessary, and made available in the practice setting.

These policies and procedures should include, but not be limited to,

items to be counted,

directions for performing counts,

procedures in which baseline and/or subsequent counts may be exempted,

alternative or additional safety measures for special circumstances, and 4

nursing actions and procedures for incorrect counts.

Policies and procedures establish authority, responsibility, and accountability and serve as operational guidelines. Policies and procedures also assist in the development of patient safety, quality assessment, and improvement activities. 18 Nurses should collaborate with all members of the surgical team to develop policies that address surgical counts. 12,15

2. Practices, policies, and procedures are subject to change with the advent of new technologies.

3. An introduction and review of policies and procedures should be included in orientation and ongoing education of perioperative personnel to assist them in obtaining knowledge and developing skills and attitudes that affect patient outcomes.

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Why are the instruments counted at the end of the surgical procedure?

Why are sponges counted during a surgical procedure?

What items are included in a surgical count?

What is the significance of counting all surgical instruments and sponges before the start of surgery and before closure of a surgical site?