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No Sponges Left Behind
Charlene DiNobile, Lisa Reed
Publish Date: July 13, 2008   |  Tags:   Patient Safety

You might have a surgical count policy, but reports of retained sponges, instruments and needles indicate that not everyone is sticking to the 6 C's of surgical counts.

1. Competency. Develop competency tools to test team members' count skills. A scrub demonstrates competency in counting sponges by breaking the paper tapes, separating the sponges and counting audibly with the circulator. If she misses any of these steps, more training is needed.

2. Consistency. When performing a count during a procedure or wound closure, staff must be consistent in the sequence they follow. Many facilities require counts to begin on the field, continue to the back table and then finish off field. But the order doesn't matter — as long as it's consistent with your facility-wide policy.

3. Commitment. The entire surgical team must be committed to the count. That means letting both the circulator and scrub perform the count without interruption.

4. Communication. Keep the lines of communication clear during the count process. Conduct a new count each time there's a permanent staff change in the OR. The circulator should also indicate on the count worksheet any extra items that are added to the field during the procedure and who added them.

5. Closure check. The surgeon performs the closure check by visually and manually sweeping the cavity or wound before closure. The physician notifies the circulator when the closure check is complete.

6. Check up. To ensure your surgical count protocols are being followed, review your policy and survey your staff regularly. Chances are you'll find discrepancies between policy and practice. You'll also find that interpretations of the policy differ from employee to employee. The best way to combat these inconsistencies is to conduct periodic, unannounced audits during procedures.

Create a checklist that details every step of the process as prescribed by your official policy (you can modify our "Surgical Counts Audit Tool" on page 25). The auditor should remain in the OR from the beginning of the count until final counts have been completed. This lets the auditor assess the entire count procedure — including, if necessary, the reconciliation of a missing item. The auditor should compare the count documentation to the actual items that are on the sterile field, making sure they match up. Documentation tools may include hard copies of the count sheet, whiteboard or electronic documents.

After the audit, track incorrect counts carefully. Have your entire staff openly discuss near misses — every team member is accountable for such mistakes. Then examine your existing policy and see if there's anything you should do differently to minimize the risk. For example, ask if new tracking technology — such as handheld wands that can be used to detect sponges containing radio frequency identification chips — is right for your facility.




All Counts

  • All sponges, instruments, sharps and other miscellaneous items are counted by both the circulator and scrub before the patient enters the room.
  • Items should not be placed on the Mayo stand until all baseline counts have been completed. (This may be facility-specific; please refer to your policy).
  • Counts are performed in a systematic manner.
  • Items should be counted in the order that is listed on the count sheet.
  • Circulator documents each item on the count sheet.
  • Any items added during the procedure are counted and added to the count sheet.
  • A count is performed during closure of a cavity.
  • A count is performed before the wound closure begins.
  • All counted items remain in the OR until the procedure has been completed and the final count has been verified. Surgeon is notified of the count results.



Sponge Count

  • Only radiopaque intact sponges are on the surgical field.
  • Paper tapes wrapped around the sponges remain intact until the sponge count begins.
  • When counting, sponges are separated and counted audibly and viewed by both circulator and scrub.
  • Sponges are counted during skin closure.
  • Discarded sponges are placed in a leakproof receptacle that is easily visible by the team members who are counting. (For better visualization, pocketed count bags or other systems are recommended.)
  • Any sponges intentionally left in the patient must be documented.



Sharps Count

  • All sharps and other items (suture reels, vessel loops, scratch pads) are counted.
  • Sharps are counted during skin closure.
  • Suture needles are counted according to the number marked on the package and verified by the scrub when the package is opened.
  • All sharps are to remain confined. Used sharps are placed in a puncture-resistant container.
  • Any sharps that become broken must have all of the parts accounted for and verified.



Instrument Count

  • All instruments that have extra pieces (such as a Balfour retractor) should be accounted for separately on the count sheet.
  • If instruments have a similar tip (such as a Kelly clamp and Kocher), the tips must be visually inspected by both circulator and scrub.
  • Any broken instruments must have all of the parts accounted for and verified.



Reconciliation for Count Discrepancies

  • If there is an incorrect count, the circulator reports to the surgical team the item that is missing.
  • The closure of the wound is suspended if the patient's condition allows it.
  • A manual inspection of the operative site is performed.
  • Inspections of the surgical field, floor, kick buckets, trash and linen receptacles are performed.
  • If the item is found, the count is repeated and verified.
  • If the item hasn't been found, an intraoperative X-ray is performed as long as the patient's condition allows it.
  • The X-ray is read before the patient and surgeon leave the room.
  • The results of the count are documented.
  • The incident is reported according to facility policy.