How do you resolve an incorrect count at your facility? Whether it's as simple as a dropped hemostat that you didn't hear hit the floor or as serious as a missing sponge that didn't show up on a foreign body X-ray, you would hope that your surgeons and staff would follow your incorrect count policy to the letter, taking exactly the right steps in exactly the right order whenever the count is incorrect, unresolved or unreconciled.

Of course, we know that's not always the case. Not all of the staff scrubbed in for a case are familiar with your policy, and some surgeons rarely encounter incorrect counts. In the heat of the moment, there can be a lot more questions than answers.

• When does the surgical team continue or pause closure? When do they search for the missing item or order a foreign body X-ray?
• When does the scrub tech conduct a first closure count or repeat count? When does she continue to search for the item?
• When does the circulator conduct a first closure count or repeat count? When does she inform the attending surgeon or call the OR desk/charge nurse? Does she place a foreign body X-ray order?

That's a lot to remember and a lot to do. What every OR team could use is a step-by-step, role-defined guide to help resolve incorrect counts. We think we've come up with a pretty good solution — and it hangs prominently on the wall in all 80 of the ORs here at the Ohio State University Wexner Medical Center in Columbus, Ohio.

When a count is off, our OR teams simply look up at our "Incorrect Count Algorithm," a 22 x 33 inch poster that condenses our 11-page policy for resolving incorrect counts into a set of steps that you follow in order. We used eye-catching colors to outline role-defined tasks. We've found that an easy-to-follow infographic is the best way to organize and structure complicated information.

The false sense of security from an apparent negative foreign body X-ray deceived us into discharging the patient with the count still unresolved.

Our retained object case

Necessity is the mother of invention, right? We created our poster in response to a retained surgical item that happened on our watch in 2016. During a neuro case, we left behind a tiny sponge like the one I'm holding in the photo on page 32.

The case, a Chiari malformation decompression, was unremarkable until the first closing count was off — a 1 by ? inch cottonoid was missing. The OR team followed the proper protocol for an incorrect count at the outset, but they veered away from the policy and, as a result, discharged the patient with a retained object. Here's a recap.

The attending surgeon verbally ordered a foreign body X-ray and the radiology tech took a lateral foreign body film. The circulator scanned the garbage, the floor and the other nonsterile areas of the room, while the surgical technologist hunted through the sterile area, checking the drapes around the patient and the instrument table. The search came up empty.

They read the film. Negative. Stating with supreme confidence that the sponge couldn't be inside the patient if they couldn't locate it on the X-ray, they closed up the patient. The false sense of security from an apparent negative foreign body X-ray deceived us into discharging the patient with the count still unresolved. There's an important lesson: Don't put all your faith in foreign body X-rays, which can be difficult to read, especially if the patient is obese and in the prone position, as ours was. The neurologic wiring in place from the Chiari malformation decompression further obstructed the view of a sponge that's smaller than a stick of Dentyne. Had we followed our incorrect count policy all the way through, we likely would have found the retained object.

What should we have done?

With the count still unresolved, the OR team should have paused the closure. The attending surgeon should have explored the wound and pored over the X-ray once again with the radiologist. None of this happened. By the way, the sponge was spotted months later on a follow-up film unrelated to the surgical procedure. Here are some takeaways:

• Staff won't memorize your policy. Don't expect staff to retain what they read in your count policy. Yes, you hold in-services on resolving incorrect counts, but that doesn't mean staff will remember what they should do. And remember, just because someone signs off on reading the policy does not mean she actually read it or will retain it.
• Instill a "do-your-job" mentality. Don't rely on your non-scrub person pulling the policy up on a computer and telling everyone what to do. This doesn't represent the team approach that is vital to handling an incorrect count. Also, having one person telling everyone else what they should be doing is too much responsibility for that one person. Likewise, it can cause animosity between members of the team. Each team member should fulfill their obligation.
• Don't play the blame game. To avoid finger pointing, everyone in the OR should be aware of each other's duties when you respond to an incorrect count. That's one of the beauties of the poster: Everybody can see what everybody should be doing every step along the way.

Calm, cool and collected

Our algorithm has helped us standardize our count practice, and it can do the same for you (download a free PDF at outpatientsurgery.net/forms). We hung it on the wall so no one would have to think about what to do during an incorrect count. Just calmly look up and follow the steps. OSM