Back when I was in nursing school, I spent one of my clinical days in the operating room. It was very eye-opening. The circulator in the room let me stand as close as possible to the field so I could see everything. I watched a urologist insert penile implants during one case. I’ll admit, that was a little weird for my young, naive self, but still, it was very interesting. And it was Valentine’s Day – that made me giggle a little bit. 😂 After that case I watched a general surgeon removing adhesions from a patient’s colon. That was cool! I’d never seen what someone’s insides looked like, so I was fascinated. I even stayed longer than my clinical time, just so I could finish watching the case.
As memorable and as fascinating as it was to watch those cases, another memory stands out, too. I can clearly remember the circulator and the scrub counting instruments before and after that second case. I remember being amazed that the scrub knew what all those different “things” were on the table. I also remember that both the circulator and the scrub participated in the surgical count. I don’t remember much else about it, but the memory of them counting instruments has stuck with me for 17 years.
Fast forward to today, and I participate in the surgical count in every case that I do. It’s part of my job, and part of making sure my patients stay safe. But it’s really easy to take the count for granted, or for it to become just another mundane task. And when it becomes just something else that we have to do, another check in the block, we forget how fundamentally important the surgical count is for our patient’s safety.
So why is the count so important?
The biggest reason surgical counts are so important is because we don’t want to accidentally leave something inside of our patients! This seems simple enough, right? But when you do the same thing, day after day, it’s easy to forget why we’re doing what we’re doing.
What does AORN say about surgical counts?
According to the 2016 AORN Guideline for the Prevention of Retained Surgical Items (RTI’s), an evidence-based strategy for preventing RTI’s is to account for what we use during operations and invasive procedures. We count radiopaque soft goods, sharps, miscellaneous items, and instruments so that we can keep track of what is on our sterile field. This helps ensure that all of those items are still on our sterile field at the end of the case, and not inside of our patient.
Each healthcare organization is responsible for providing a standardized and reliable method that keeps track of all surgical items used during a procedure. Your organization’s policies and procedures will dictate how surgical counts should be performed at your facility. The AORN guidelines are the optimal practice, and they are adaptable to any area where operative or invasive procedures may be performed. (Source)
Who is responsible for surgical counts?
Everyone in the room is responsible for the accuracy of the count. This is a fundamental way that we as a team prevent retained items. But, let’s break it down a little further:
What does the circulator do?
- Initiate the surgical count and participate in it.
- Visualize the items on the sterile field as they’re being counted.
- Don’t sit at the computer while your scrub yells out numbers to you. Get up and go look at everything!
- Ensure that the count is visible to the room.
- Start each case with a clean white board/count sheet.
- Remove any leftover, countable items from a previous case, before beginning a new one.
- Keep track of any items that are dropped on the floor.
- If a suture, lap, raytec, etc., drops on the floor, don’t throw it away! Make note of it and set it safely aside so it can be accounted for during final counts.
- Document the surgical count
- If there’s an incorrect count, communicate and document per protocol
What does the scrub do?
- Participate in the count!
- Don’t leave it up to the circulator to look at the back table and make sure everything is accounted for!
- Have an organized sterile field.
- Keeping the sterile field well organized makes it easier to find items.
- Always know the location of soft goods and instruments within the sterile field.
- Alert the circulator any time an item is placed inside the patient (packing in the throat, lap inside a wound, etc) so it can be documented.
- Verify all items are intact when they are returned to the back table.
- Examine suture to make sure they’re not broken, for example.
- Always count items in such a way that the circulator can visualize what is being counted.
- Picking up a pack of pop-offs and saying, “eight” and not taking them time to count them individually is incorrect.
Our surgeons have responsibilities as well. They should always allow us to perform a count and not hinder our ability to do so. They should inspect the wound before closing to make sure nothing has been left behind. They should also communicate clearly when items are placed inside the patient.
And don’t forget:
- Always have a consistent method for counting.
- Don’t try to count during critical parts of the case.
- Remove or reduce distractions during the count.
- Always perform a count when relieving a circulator or scrub during a case.
Remember, we’re all a team.
By working together, we can ensure the accuracy of our counts every time we perform an operation or invasive procedure. An accurate count can help us reduce the risk of having a retained item. And surgical counts exist to protect our patient from the complications that would arise if something were left inside them. They also exist to help protect us from the far-reaching consequences of a retained surgical item.
Do your part – you play a vital role in patient safety by keeping an accurate count.
It’s not just another mundane task or a check in the block. Actively participate and help safeguard your patient from the damaging effects of a retained item.
Here’s to accurate counts for circulators everywhere,
Melanie
My main source for this article, other than my own experience, was AORN’s 2016 Guideline for the Prevention of Retained Surgical Items.