What to Do When Counts Go Wrong?

Patient Safety

By: Outpatient Surgery Editors

Published: 10/3/2008

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OR staffing changes can interfere with accurate sponge counts.


A recent study shows that discrepancies in surgical counts occur in one out of every eight surgeries. Those discrepancies, which can involve a misplaced or lost sponge, instrument or needle, occur most often when there is a staffing change in the OR.

To avoid the kind of confusion that can occur when circulating nurses or surgery techs switch off in the midst of a procedure, professors Charlene DiNobile, RN, CNOR, CNAA, CST, and Lisa Reed, CST, RN, CNOR, of the New England Institute of Technology recommend that the surgical team conduct a new count each time there's a personnel change in the OR. If there's a discrepancy in the count, the circulator should report the missing item to the surgical team. Ms. DiNobile and Ms. Reed then prescribe the following course of action:

 

  • Suspend closure of the wound if the patient's condition allows.

     

  • Manually inspect the surgical site, as well as the surgical field, floor, kick buckets, trash and linen receptacles.

     

  • If the item is found, repeat and verify the count.

     

  • If it isn't found, perform an intraoperative X-ray and read it before the patient and surgeon leave the room.

     

  • Document the final results of the count and report any incidents according to your facility's policy.

    For more tips from Ms. DiNobile and Ms. Reed on improving your surgical counts, see their article, "No Sponges Left Behind."

    —Irene Tsikitas

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