Surgical counts have been documented in clinical practice since the beginning of the 20th century.1 AORN published its first standards for counts in 1976. In spite of these efforts, retained object medical errors still occur. What's more, surgical personnel may not even realize how they're committing these errors. A recent study showed that in 88 percent of cases involving an item left inside a patient, the closing count was documented as correct.[2]

Retained object errors are rare, but they're extremely costly. They require a patient in now-compromised health to undergo additional surgery, another round of anesthesia and its effects, more pre-op anxiety and post-op pain, and the continuing threat of infection. They also put your surgical team and facility at legal and professional risk.

Our focus on preventing this type of error originated from staff members witnessing the aftereffects of retained objects on patients. Reviewing our practice in relation to counts, we investigated where deviations might occur and where mistakes could be made. We identified several opportunities for error in surgical transitions — handoffs, shift changes, breaks and the ends of cases — when proper relief counts weren't conducted.

It seems hard for non-medical observers to believe that a surgical team could leave a sponge, a blade, a syringe, a Bovie tip or a Kelly clamp inside a patient. But every year we see reports of retained items. The reason is, we're all human, and when it happens, it is most definitely human error. A review of the literature shows that the factors most likely to lead to a retained object error, as with many other types of medical errors, include the following:

• failure to count sponges and instruments or to properly manage counting procedures;
• ineffective communication patterns, especially if a surgical team takes one member's word that a count is correctly done;
• unplanned changes in procedure;
• worker fatigue or distraction;
• a change in the nursing staff during a procedure;
• a procedure that involves more than one surgical team;
• a patient who is female;
• a patient who has a higher-than-average body mass index;
• an increased loss of blood;
• a complex procedure; and
• emergency surgeries.[2]

The beat-the-clock atmosphere that exists in some facilities can compound these risk factors. Unfortunately, the business culture in today's clinical settings "places a higher priority on efficiency and decreasing turnover times than on counting."[1]

Some ambulatory facilities don't always do counts, arguing that with minimally invasive procedures, they're not really necessary. But consider eye cases, in which sutures are very small, nearly microscopic.

The possibilities of patient harm, professional impact and legal liability are compelling reasons to preempt this or any medical error, but a new federal policy aims squarely at the bottom line. As of Oct. 1, 2008, Medicare will stop reimbursing hospitals for patient care required as a result of eight preventable conditions, one of which is retained objects.

Our current preventive policy is based on AORN's recommended practices for counts.3 That's our bible in this area. It's what helps us to ensure a culture of safety for our patients and provides a rationale for why we take the time to do what we do. Here are some of AORN's recommendations:

• Perform an initial count on all procedures to establish a pre-procedure baseline.
• Separate packaged surgical supplies such as sponges and audibly count the items while two individuals, including one RN, look on.
• Never assume that pre-packaged items have already been counted correctly. Manufacturing errors can and do occur. We've seen packages of sponges containing six instead of five, or nine or 11 instead of 10, and we've also found that when one manufacturer's miscount occurs, it's not uncommon to see another in the product lot.
• Disposable surgical supplies should remain in their original form — don't cut or otherwise alter them. Counted items should remain in the OR for the duration of the procedure.
• All supplies and instruments should be X-ray detectable. The sponges we use during surgery have radiolucent threads or strings attached to them so we can find them using intraoperative imaging if we need to. Don't use the specially detectable sponges for dressings outside of surgery, since an overuse may later require the use of non-detectable sponges during open cases.
• Compare follow-up counts with the initial baseline count at the relief of the scrub or the circulating nurse, before the closure of a cavity within a cavity, before wound closure begins and at skin closure or the end of the procedure.
• Conduct counts in the same sequence each time, from the surgical site to the Mayo stand to the back table, to establish an orderly and repeatable routine.
• We've made it a rule that if the closing count for sharps, sponges or instruments turns up incorrect at the end of abdominal or other open procedures, we'll X-ray patients before they're extubated.

Put into practice
Beyond AORN's recommended practices, we've refined a few areas of policy and put into place a few steps to improve our prevention strategies.

Education is a solid foundation on which to build safety. We make every single surgical individual on our staff, from scrub techs to RNs to physicians, aware of our policy and procedure on counting. As part of orientation, we require new employees to demonstrate the proper counting method to us. This probably sounds like overkill, and we did meet some initial resistance — "I've been doing this a long time," said some staff members who felt that having to count for us was juvenile. But we got a better buy-in from them following a presentation by our risk management specialists, who discussed real cases of retained object errors and how they affected the lives of patients and their families.

Effective perioperative communication is another key to clinical safety. You want to guarantee that handoffs are done in a manner in which everyone is informed and to maintain this consistency. We installed whiteboards in every OR as an aid to this communication and to help monitor counts. Every time you add a sponge or a sharp to the surgical field, you mark it on the board, while instrument additions are placed on the instrument count sheet. That way you have a running tally of how many items you're supposed to have at the end of the case. It forces you to visualize what you're counting, and not just assume when you can't physically see something. Making our staff use the boards involved a bit of a learning curve. Change is very difficult in the OR environment. Even though we're exposed to near constant change in technology and procedures, OR personnel don't always respond well to change in practice.

Your nurses and scrub techs can't be afraid to ask your surgeons to stop because they can't see everything in the field for a count or the count, once completed, isn't correct. We tell our surgeons that we're not going to stop them unless we have to out of concern for patient safety. They'll pause while we go through the garbage and get down on our hands and knees to search the floor. We'll do whatever it takes to maintain a safe environment.

References:
1. Beyea SC. "Counting instruments and sponges." AORN Journal 2003. 78: 290-294.
2. Gawande AA et al. "Risk factors for retained instruments and sponges after surgery." NEJM 2003. 348: 229-235.
3. "Recommended Practices for Sponge, Sharp, and Instrument Counts." AORN Journal 1999. 70: 1083-1089.