“NOTHING LEFT BEHIND” THE SURGICAL COUNTING in ISRAEL`S O.R A NATIONAL RESERCH EDNA LAVI, RN, ORN, BA RAMBAM HEALTH CARE CAMPUS HAIFA, ISRAEL

INTRODUCTION  Mistakes and almost mistakes in surgical counting put the patient’s life at risk.  Patient safety is at the center of the operating room nurse’s philosophy.  It is important to use risk management in the OR routine in order to prevent mistakes in surgical counting.

FACTS  There are different interpretations in the recommended practices for surgical counting.  There are great differences in the actual performance of processes.  We have to change certain general guidelines in order to reduce mistakes and almost mistakes in surgical counting.

AIM OF RESERCH  Reduce the number of mistakes and almost mistakes in the operating room.  Establish uniform work procedures in all operating rooms in Israel.  Reduce interpretations to written policies.  Assimilate correct work processes.

METHODOLOGY  Anonymous research questionnaires included OR nurses from 16 hospitals.  500 questionnaires were distributed.  345 nurses (69%) answered the questionnaires.

BASIC ASSUMPTION the possible factors causing mistakes/possible mistakes in the surgical counting are: The human factor. The environment factor. The process's failure.

THE QUESTIONNAIRE Included 4 aspects:  Operating room nurses’ beliefs in relation to factors that contribute to the making of mistakes in surgical counting.  nurses’ training and OR seniority in relation to factors that contribute to process failure.  The counting process as it is actually performed.  Documentation in cases of a mistake in counting.

RESERCH RESULTS

DIVISION OF NURSES ACCORDING TO TRAINING AcademicLicensedRegistered

DIVISION OF NURSES ACCORDING TO SENIORITY 30+ YEARS YEARS YEARS 6-10 YEARS 1-5 YEARS

MAPPING THE COUNTING PROCESS

MAPPING THE COUNTING PROCESS SPECIAL CASES

WHEN THERE IS A COUNTING DISCREPANCY

NURSES ATTITUDES - FACTORS CONTRIBUTING TO COUNTING MISTAKES

NURSES’ TRAINING AND FACTORS CAUSING COUNTING MISTAKES

SUMMARY OF RESULTS A significant difference has been found in the following cases:  The strictness of the count process when there are 2 nurses in the OR.  The count report in nursing documents (less then 80%).  A significant difference in counting in special cases such as fat patients, donation cases, etc.

 A different in the items counted.  A reduction in the strictness of reporting during staff changes.  A difference in policy about documentation and X-rays in cases of counting discrepancies.  A difference in actions taken in cases of counting discrepancy. SUMMARY OF RESULTS (cont.)

DISCUSSION

THE HUMAN FACTOR There is a limit on the human brain and it donates to human error even in such simple acts like counting to ten.

THE ENVIRONMENTAL FACTOR  A stressful, complicated, and distraction prone environment in operating rooms may cause a lot of confusion and human error.  Disinformation between O.R staff, because of masks, glasses and other protective equipment causes a failure in communication.

THE PROCESS Failures in the process may be caused by:  Deviation in the counting process routine.  Not working according to written policies and procedures.  Nurses’ slackness in process performance.  Inadequate report and documentation.

RECOMMENDATIONS  To emphasize the importance of patient safety as a foundation to quality improvement.  To write clear and understandable policies that are not open for personal interpretation.  To establish a risk management system to inspect actual practice.

 To create a case study learning system.  To use an ergonomic thinking process aimed at improving and assimilating work and counting processes. RECOMMENDATIONS (cont.)

HOW CAN WE DO IT?

 Written clear national guidelines and procedures for sponge, sharp and instrument counts that define materials to be counted, the time for counts, and the documentation required.  Periodically refreshing staff knowledge.  Providing an atmosphere of obligation to documentation and reporting.

Summary  The safety and welfare of patients during surgical intervention are the primary concerns of peri-operative nurses.  Policies and procedures are designed to ensure the safety of patients and staff and must be followed.

 As human beings, we have the potential to make mistakes and injure patients by forgetting foreign bodies in a patient's operative site. Therefore, the counting process must be an integral part of all procedures in the O.R.  A risk management policy ensures safe patient care. Learning from it we can reduce and prevent cases of mistakes and almost mistakes in counting processes.

WHAT HAVE WE ALREADY DONE?  We send the research book to the nursing division in ministry of health in order to be a part of the writing regulation committee.  Nursing division in ministry of health opened a course include novice nurses and un-experienced nurses to prepare new generation in OR.  We published our research among head nurses in OR.

The point is We want to ensure that every case is preformed safely and that our surgical tools remain where they belong – in the OR and nothing is left behind. IT IS EASY AS 1-2-3