1. Counting of accountable items
Chan Suk Ming, Maria
APN, Operating Theatre
Queen Elizabeth Hospital

2. Objectives To explore the importance of counting.
To identify the risk and impact of retained foreign bodies in patients’ bodies after operation.
To explore the legal liability of OT personnel after the critical incident.
To learn the “Principle of Counting”
To identify ways to reduce risk.

3. Why count?
“COUNTS are performed to account for items …
ensure that the patient is not injured as a result of a retained foreign body”
AORN Recommended Practices for Sponges,
Sharps and Instrument count
對...負有責任,保證

4. What are the accountable items during operation?
Anything that is opened onto the sterile field are known as “accountable items”
1. Sponge
(Raytec gauze, dental swabs and patties)
2. Sharps (Suture, needles, blades, needles, trocar, diathermy pen tips)

5. 3. Instruments
(all kinds of instruments including the screws, coating)
4. Miscellaneous items
(cotton tapes, surgiloops, cautery pads etc.)

6. When accountable items are not counted and documented 
a potential risk of retained foreign body.
To prevent this problem:
: Counting policy must be reviewed and revised.
建立政策

7. Guidelines for Specialty Nursing Services (perioperative Care)
ORQS –Operating Room Quality and Standard committee

8. What is foreign body?
Anything that does not naturally belong to one’s own body.
Introduced from outside intentionally or accidentally

9. Foreign bodies intentionally left with patient
Implants
Sutures
Auto-sutures
Allograft
Surgicel/Gelfoam
Gauze/Swab

10. Foreign bodies accidentally left with our patients
Gauze/swab
Instrument/Missing parts of an instrument/screw
Broken Drill Bit
Broken wire
Diathermy tip and tip cleanser
Surgiloop
Gloves

11. The most common surgically retained foreign body is ?????

12. According to the research done by the ECRI Institute
Retained foreign objects (RFOs) in surgical patients show that
 sponges are the items most frequently reported as retained
 followed by instruments
學院 ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.      

13. Accuracy of the count affected by:
The complexity of the surgery
The urgency of the surgery
The surgical team’s fatigue (duration and late-day procedures)

14. Human Factors in the Counting Process
Communication failures
Distractions from multiple competing interests
Pressure for increased productivity
Lack of sufficient personnel

15. Case Study

16. Removal of PICC PICC placed at a hospital.
On its removal, the catheter was broken and missing.
Where had it gone????

17. This catheter fragment had embolized 栓塞
to the left pulmonary artery

18. Migration of the catheter fragments
Along the blood stream finally lodging in either:
: Vena cava
: Right atrium
: Right ventricle
: Pulmonary artery

19. Serious complications:
Myocardial perforation 心肌穿孔
Myocardial infarction 心肌梗死
Valvular perforation 瓣膜穿孔
Arrhythmia 心律失常
Cardiac arrest 心臟驟停
Endocarditis 心內膜炎
Pulmonary abscess肺膿腫

20. Thoracotomy
In 2003 Europe
TSSU staff reported  rib approximator  screw missing
X-Ray taken in the RR and the screw was found in patient’s chest
Patient was sent back to theatre for re-operation.

21. This case highlights the importance of
: checking the small connections of the instrument
: especially if an instrument become loose.

22. Possible risks that could happen after the critical incident
Re-operation
Perforation of internal organs
Sepsis or infection
Readmission or prolonged hospital stay
Death

23. Legal aspects 法律標準 Washington - since 1929:
“When a surgeon inadvertently leaves a foreign substance in the body with no possibility of any therapeutic purpose, the act constitutes negligence 疏忽”
“合理謹慎”的法律標準，華盛頓已經認識到
謹慎小心, 不慎地 非故意地

24. Case study
“In Van Hook, the hospital had a policy that required the nurses to account for all swabs.
The nurse had told the surgeon the swabs had been all accounted for when, in fact, they had not.

25. The Van Hook court held the surgeon not liable because the swab count was the nurses’ responsibility.”

26. “In many states, a retained foreign body will be considered negligence per se.”
“When cases are avoidable and cause injuries to our clients, many lead to mal-practice claims索賠”

27. Legal aspect
“The law does not require that objects in the surgical field be counted – only that nothing inadvertently be left within the wound.”

28. Canadian Journal of Surgery 2004
The Canadian Association of General Surgeons initiated a program called “Evidence Based Reviews in Surgery”.

29. Setting: A malpractice insurance agency and 10 hospitals in the state of Massachusetts from January, 1985 to January, 2001.

30. The study includes 54 patients with a total of 61 retained foreign bodies

31. Characteristics of 54 cases of retained foreign bodies after OT
Types of foreign bodies retained
Others: vessel loop, cotton tape, gloves, pen tips

32. Cavity in which foreign body was left

33. Outcomes Death (2%) Readmission or prolonged hospital stay (59%)
Sepsis or infection (43%)
Re-operation (69%)
Bowel obstruction (15%)
Visceral perforation 內臟穿孔 (7%)

34. Risk factors identified
Lack of a complete count of swabs , needles and instruments
Change in nursing personnel during surgery

35. Fatigue in the surgical team
Talking, talking and talking
Obesity of the patient

36. Urgency of the surgery
Excessive loss of blood

37. An unexpected change in a procedure
The involvement of multiple surgical teams

38. Preventive measures for retained gauze in patients’ bodies
1. Use Raytec gauze for all procedures no matter how minor or how superficial the wound is.
2. Non-radio-opaque swabs should not be available to the surgical team until the wound is closed.
3. No radio-opaque gauze should be used for dressing

39. 4. Raytec gauze should never be cut into pieces
5. Record all gauzes opened onto the sterile field
6. Gauze must placed within the operating room until all counts completed

40. 7. Check that swabs from the previous operations have been removed
8. Take special care during major, multiple operations

41. 9. When surgeon packs a gauze in a cavity, record it on the whiteboard/count sheet.

42. 10. ↓ Change of OT personnel during operation.
11. Hand over  a full swab and instrument check

43. 12. Surgeon should allow sufficient time for checking upon closure.
13. Scrub personnel should report the count result to the surgeon.

44. 14. Scrub personnel should inform the surgeon of any discrepancy
15. Count gauzes according to standard and guidelines.

45. Principle of Counting
1. Count all accountable items that possesses the likelihood to be retained in patient’s body

46. Principle of Counting 2. Two personnel – one must be Registered Nurse:
: View concurrently
: Count audibly
: Same sequence

47. Principle of Counting
3. Maintain concurrent information for all accountable items throughout the operative procedure 4. Perform counts for all accountable items before the procedure to establish a baseline for subsequent counts
update

48. Principle of Counting
5. Perform counts when additional accountable items are added to the sterile field. 6. Perform counts for all accountable items prior to closure of a cavity within a cavity 7. Perform counts for all accountable items before wound closure begins

49. Principle of Counting
8. Perform counts for all accountable items at skin closure or the end of the operative procedure(s). 9. Adopt progressive counting away technique throughout the operating procedure

50. Progressive counting away technique
Should be performed and documented by circulating person, witnessed by the scrub person, one of whom should be RN.
All gauze and swabs should be counted away in multiple of 5 or 10, or as per original packaging.
All counted away items should be kept in an isolated and sealed receptacle.

51. Principle of Counting
10. Confine all accountable items, including all counted away items, in the operating room until after completion of the operative procedure.
11. Check all accountable items for entirety throughout the operative procedure.

52. Principle of Counting
12. Confirm with the surgeon concerning the status of the count at closure of each body cavity and at the end of the operative procedure. 13. Perform counts for all accountable items at the relief of the scrub person.

53. Principle of Counting
14. Initiate appropriate actions when discrepancy of counts occurs.
15. Maintain an accurate documentation of the count result.
16. Document the retention of accountable items intentionally left in patient’s cavity

54. Counting of instrument
Instrument check lists should be available
Should be used to check the instruments at the beginning and end of every case.

55. Instruments with screws, removable parts must be checked.

56. Instruments should be counted before they are separated and set up on a mayo table

57. Any damaged instruments or not working properly 
must be removed and labeled for repair
Staff involved in counting 
must be able to recognize the instruments they are counting.

58. If an instrument tray is incorrect during the initial count 
it should be either be removed and a new one opened or
continue to be used if the scrub person is satisfied that the instrumentation required for the procedure is present.

59. However, in both circumstances, the missing instrument must be
: documented on the instrument check list : TSSU informed.

60. If the returned instrument is not complete:
 inform NO I/C
 notify the surgeon to search the wound.  scrub personnel searches the sterile field and circulating searches the floor, linen and garbage bags.

61. If the missing parts of the instrument cannot be found, check with X-Ray.
Whenever the patient has got an unnecessary X-Ray  no matter the missing parts can or cannot be found, document in the Nursing Record.

62. Progressive Counting away of instrument
Can be done to assist in the management of large numbers of instruments.
Must be counted by the two personnel, one must be RN and removed from the sterile field.

63. Hospital should clearly define circumstances in which the instrument count may be waived.
Complex procedures with large numbers of instruments
Trauma
Procedures require complex instruments with numerous small parts
Procedures where the width and depth of the incision is too small to retain an instrument

64. Preventive measures to prevent sharps/instruments retained in patients’ bodies
Sharps like needles and blades used by surgeon should be counted and recorded, no matter how minor or superficial wound is.

65. Check each sharps after use to ensure that they are complete.
When powered tools are used, check that attachments, saws, blades, burrs, drill bits are complete after use.

66. When using Laparoscopic instruments 
check the instrument screws and coating upon return by surgeons.

67. Maintenance of instrument should be done regularly
: Screws tightened
: Joints lubricated
: Osteotomes/Chisels sharpened
: Powered instruments lubricated
: Blunt drill bits/tap replaced
: Scissors sharpened

68. Care should be taken not to cut cotton tapes, surgiloops
Cotton tapes, surgiloops and patties used on the operative site should all be counted.

69. Steps to follow when there is a “Count discrepancy”
Recount
Inform NO I/C, room I/C, circulating nurse and surgeons.

70. Conduct search:
: Surgeon searches the operative field
: Scrub person search the sterile field

71. Circulating nurse search
linen
garbage bags
under bed and tables
rest of the theatre

72. Recount
If not found, check with X-Ray

73. Count Results
If correct: Document on intra-operative record

74. If incorrect after search
Check X-Ray:
Document on intra-operative record
Report incident in AIRS (Advanced Incident Reporting System)

75. Sharps: Needles, blades, drill bits…
Sharps broken during a procedure must be accounted for their entirety.

76. If the sharps are broken and are not completed during the procedure:
 notify surgeons and NO IC.
 If the surgeon determined not to remove the broken parts  Documentation

77. How to record broken instruments left within patients’ body?
 Record the nature of the broken instrument
 Record the size of the broken instrument
 Record the name of the surgeon who decided to leave the broken parts within patients’ body
 Record the name of the NO IC who you have reported the incident

78. Risk Reduction Strategies
Counting alone may not prevent postoperative retention of a foreign object.
Routine X-ray screening
Assistive Technology

79. Postoperative X-ray screening
Stainless steel instruments are likely to be detected
X-ray is less sensitive in detecting sponges and needles
Sponges may twisted or folded, or a non-radio-opague sponge being used
Needles may be difficult to visualize due to their size

80. Assistive Technology Radio-frequency (RF) detectable sponge systems
Bar-coded sponge systems

81. Radio-frequency (RF) detectable sponge systems

82. Bar-coded sponge systems
Each individual sponge has a unique two-dimensional bar code
no one sponge can be counted twice and inadvertently create a false correct count.

83. These aids are used in addition to the manual count, not replace it.
X-ray is not always effective in identifying retained foreign bodies.
In one study, 67% of intraoperative X-ray were read as negative when a retained foreign body was actually present.