INSTRUCTIONS & DISCLOSURE STATEMENT Course 10: Perform Sponge, Sharp, and Instrument Counts Purpose/goal Statementt The purpose of this chapter is to describe the perioperative nurse s role in preventing retained foreign bodies during operativee and invasive procedures. Target Audience: Perioperative RNs Objectives After reading this chapter, the participant should be able to: 1. Identify the patient s risk for adverse outcomes related too the retention of extraneous objects. 2. Describee the count procedures for sponge, sharps and instruments. Requirements for Successful Completion Using this self-directed learning module: 1. Review the above learning objectives. 2. Read and review the course which is available at: http://www.cc-institute.org/docs/phippenchapters/2012/08/30/course-10.pdf 3. Access the online quiz which is available at http://start.cc-institute.org/s3/phippen-course-10 4. Provide your purchase order number as found on the CCI bookstore order confirmation email. If you have trouble locating this, pleasee contact CCI at 888-257-2667. 5. Completee the evaluation questions and successfully pass the ten item multiple-choice quiz. A score of 70% is equired to pass, and you have two attempts. 6. Receive certificate of completion and 0.9 contact hours in approximately 2-3 weeks. If you hold the CNOR and or CRNFA credential, the contact hours will be added to your online CCI account. Sponsorship Neither the program planners, authors, or reviewers have any conflict of interest related to this program. No commercial or n-kind support has been obtained for this offering. There is no discussion of a product used for a purpose other than for which it is approved by the FDA. This activity was approved for 0.9 contact hours by the Competency and Credentialing Institute, an approved provider of continuing education by the California State Board of Nursing, Provider number 15613. Activities that are approved by CCI are recognized as continuing education for registered nurses. This recognition does not imply that CCI or the California State Board of Nursing approves or endorses any product in the presentation. The contact hours for this activity will expire on June 17, 2014.
CHAPTER 10 Perform Sponge, Sharp, and Instrument Counts Mary O Neale INTRODUCTION Sponge, sharp, and instrument counts are performed by the registered nurse to reduce the potential for injury to the patient as a result of a retained foreign body. This crucial activity is an integral component of safe patient care during the operative and invasive procedure. Because nurses have a critical responsibility to provide safe patient care, they should determine the patient s risk for poor outcomes related to the retention of foreign bodies before every procedure. MEASURABLE CRITERIA The nurse demonstrates competency to ensure that the patient is free from injury related to retained sponges, instruments, and sharps by: Identifying the patient s risk for adverse outcomes related to the retention of extraneous objects; Initiating count procedures that reduce the patient s risk for retained extraneous objects; Initiating incorrect count procedures; and Documenting count procedures according to facility policy. Chapter Contents 283 Introduction 283 Measurable Criteria 283 Role of the Nurse 284 AORN Recommended Practices 284 Facility Policies and Procedures 284 Legal Issues 285 Identifying the Patient s Risk for Adverse Outcomes Related to the Retention of Extraneous Objects 286 Initiating Count Procedures That Reduce the Patient s Risk for Retained Extraneous Objects 288 Initiating Incorrect Count Procedures 288 Documentation and Communication Procedures 289 Conclusion 290 References ROLE OF THE NURSE Members of the surgical team are responsible for taking the measures necessary to provide safe patient care. The circulating nurse makes certain that the facility s counting policies and procedures are followed and that the required counts are performed. The scrub person collaborates with the circulating nurse to account for all sponges, sharps, and instruments.
284 Section 2: Competencies for Safe Patient Care The Association of perioperative Registered Nurses (AORN) in its Recommended Practices for Sponge, Sharp, and Instrument Counts states legislation does not prescribe how counts should be performed, who should perform them, or even that they need to be performed; the law requires only that foreign bodies not be negligently left in patients (AORN, 2008, p. 293). Further, complete and accurate counts help promote optimal perioperative patient outcomes and also demonstrate the commitment to patient safety (AORN, 2008, p. 293). All members of the surgical team should be committed to establishing policies and procedures related to surgical counts. In the event of a lost counted item, the circulating nurse implements facility policy and procedures for reconciliation of count discrepancies. AORN RECOMMENDED PRACTICES The AORN Recommended Practices for Sponge, Sharp, and Instrument Counts (AORN, 2008) are intended as guidelines for the development of policies and procedures and are adaptable to various practice settings. These recommended practices help promote an optimal level of practice. Each practice setting should use the recommended practices to develop count policies and procedures tailored for its particular practice environment. For example, Recommended Practice III states that instruments should be counted on all procedures in which the likelihood exists that an instrument could be retained (AORN, 2008, p. 296). This recommended practice enables the facility to define what types of procedures require instrument counts. Instrument counts may be deferred for pediatric patients when there is no perceived risk of retained instruments (AORN 2008, p. 297). FACILITY POLICIES AND PROCEDURES Facilities must define policies and procedures for counts. The registered nurse must know and carry out the facility s policies and procedures. Failure to do so places the patient at risk for injury and the surgical team at risk for legal action. The facility s policies and procedures should describe: Items to be counted; The sequence for performing counts (ie, start at the incision, surrounding sterile area, Mayo stand, back table, discarded items); Procedures for which subsequent counts can be omitted after a baseline count is performed; Miscellaneous items that should be counted; and Nursing actions and procedures for count discrepancy reconciliation. LEGAL ISSUES Protecting patients from injury is one of the nurse s most critical roles. If a sponge, sharp, or instrument is left in a patient and the patient sues, and if the suit goes to trial, the jury will determine if the nurse did what any reasonable and prudent nurse would have done to account for the item before closure of the wound. Jury members will be instructed to base their decision on the evidence presented at the trial, such as expert witness testimony, AORN s recommended practices, and the
Chapter 10: Perform Sponge, Sharp, and Instrument Counts 285 Figure 10.1 Nurse counting sponges. facility s policy. Retention of sponges, sharps, and instruments may result in a verdict of negligence against the nurse (Murphy, 1991). The following cases of retained foreign bodies were reported between the years of 2002 and 2003 (Murphy, 2004): A Babcock clamp was left in a patient after a gastric bypass; A sponge was left in a patient after a Cesarean section (Fig. 10.1); An instrument was left in a patient during a cholecystectomy; and An epicardial retractor was left in a patient s heart after a triple bypass surgery. IDENTIFYING THE PATIENT S RISK FOR ADVERSE OUTCOMES RELATED TO THE RETENTION OF EXTRANEOUS OBJECTS Table 10.1 identifies the desired outcome for the patient care event of performing sponge, sharp, and instrument counts. Listed in the table are criteria for this outcome with the applicable nursing diagnosis, risk factors, and outcome indicators specific to the nursing diagnosis. Scrub and circulating nurses will find the information delineated in this table useful as they assess the patient for risk factors, plan care, and apply interventions to ensure that items are accounted for prior to wound closure. 10
286 Section 2: Competencies for Safe Patient Care Table 10.1 Performing Sponge, Sharp, and Instrument Counts Does Not Compromise or Cause Injury to the Patient Outcome The patient is free from evidence of signs and symptoms of injury caused by extraneous objects. Diagnosis Risk Factors Outcome Indicators Risk for Injury related to retained sponges, sharps, and instruments Emergency procedures that preclude counting sponges, sharps, and instruments Abdominal, retroperitoneal, and thoracic procedures Procedures in which a cavity within a cavity is entered Procedures with a large open wound or extensive operative area Patient obesity Hemorrhaging during the procedure necessitating the immediate use of a large number of sponges Procedure that involve the packing of cavities with sponges Change of nursing staff during the procedure Lenient institutional count policies and procedures Does the patient have signs and symptoms of fever? Does the patient complain of pain unrelated to incisional pain? Are there signs of intestinal obstruction? Are there signs of abscess formation? Do patient radiographs indicate the presence of a retained foreign body? Adapted from Carpentino-Moyet, L. J. (2008). Handbook of Nursing Diagnosis (12th ed.). Philadelphia: Lippincott Williams & Wilkins; Petersen C. (2007). Perioperative Nursing Data Set, the Perioperative Nursing Vocabulary. (Revised 2nd ed.). Denver: AORN, Inc. INITIATING COUNT PROCEDURES THAT REDUCE THE PATIENT S RISK FOR RETAINED EXTRANEOUS OBJECTS Counting Sponges Sponges should be counted on all procedures in which the possibility exists that a sponge could be retained; sponges should be counted (AORN, 2008, p. 293): Before the beginning of the procedure to establish a baseline; Before closure of a cavity within a cavity; Before wound closure begins; At skin closure or the end of the procedure; At the time of permanent relief of either the scrub person or the circulating nurse; and When adding sponges to the sterile field. The count should be performed by two individuals, and one of whom should be the registered nurse circulator. Count the sponges out loud, viewing each sponge
Chapter 10: Perform Sponge, Sharp, and Instrument Counts 287 as it is separated. Use only x-ray detectable sponges during the procedure. Count sponges in units of 5 or 10, depending on how they are packaged. Remove packages of sponges from the sterile field that contain more or less than the packaged number. Do not remove counted sponges from the operating room (OR) until the end of the procedure. Contaminated sponges must be handled and disposed of according to the Bloodborne Pathogens Standard of the Occupational Safety and Health Administration (OSHA) and in accordance with the facility s policies and procedures. Contaminated sponges should be placed in a leak-proof, tear- resistant container. Personnel handling contaminated sponges should use appropriate personal protective equipment (PPE). Counting Sharps Sharps and other miscellaneous items should be counted on all procedures (AORN, 2008, p. 295). Sharps and miscellaneous items such as vessel clip bars, vessel loops, umbilical or hernia tapes, vascular inserts, cautery scratch pads, and trocar sealing caps should be counted (AORN, 2008): Before the beginning of the procedure to establish a baseline; Before closure of a cavity within a cavity; Before wound closure begins; At skin closure or the end of the procedure; At the time of permanent relief of the scrub person and/or circulating nurse; and When adding sharps to the sterile field. The count should be performed by two individuals, one of whom should be the registered nurse circulator. Suture needles should be counted out loud with the scrub person and documented according to the number on the outer package. When the scrub person opens the package, the number of needles is verified. Do not remove counted sharps from the OR during the procedure. Use of a disposable punctureresistant container on the sterile field ensures containment and decreases the risk of injury. When possible, sharps should be handed to and from the surgeon using a neutral zone or hands-free technique. These techniques help prevent injury to all members of the surgical team scrubbed at the sterile field. If sharps, suture needles, or other miscellaneous items break, all broken pieces must be accounted for to prevent unintentional retention of a foreign body in the patient (AORN, 2008, p. 296). OR Operating Room OSHA Occupational Safety and Health Administration PPE Personal Protective Equipment Counting Instruments Instruments should be counted for all procedures in which the likelihood exists that an instrument could be retained; instruments should be counted (AORN, 2008, p. 296): Before the beginning of the procedure to establish a baseline; Before wound closure; When feasible, at the time of permanent relief of the scrub person and/or circulating nurse; and When adding instruments to the sterile field. The count should be performed by two individuals, one of whom should be the registered nurse circulator. Instruments should be counted when they are assembled 10
288 Section 2: Competencies for Safe Patient Care for sterilization and documented on an instrument count sheet. The initial instrument count is performed in the OR to establish a baseline for subsequent counts. If there are parts to an instrument such as pieces of a retractor (blades, wing nuts, etc.) they should be accounted for and documented on the count sheet. If an instrument is broken, the pieces of the instrument should be accounted for to avoid unintentional retention of a foreign body. Hospitals performing surgery on pediatric cases should determine when instruments counts should be performed (AORN, 2008, p. 297). INITIATING INCORRECT COUNT PROCEDURES In the event of an incorrect count, the surgical team does everything possible to locate the missing item. The following steps include, but are not limited to: Inform the surgeon and the surgical team of the discrepancy; Repeat the count; Search for the missing item by inspecting the operative site, surrounding sterile field including the Mayo stand, back table, floor, trash, and linen containers; If indicated in the facility s policies and procedures, request an x-ray before the patient is taken from the room (Fig. 10.2); and Document incorrect counts and actions taken according to the facility s policies and procedures. DOCUMENTATION AND COMMUNICATION PROCEDURES The registered nurse circulator and the scrub person should communicate regularly during the procedure about the status of sponges, sharps, and instruments. The surgeon must be notified of the results of the counts and acknowledge the results of the counts to the registered nurse circulator. Documentation of the results of the counts should be recorded in the patient s record according to the facility s policies and procedures using uniform perioperative nursing vocabulary. According to AORN s Recommended Practices for Sponge, Sharp, and Instrument Counts, documentation should include, but not be limited to (AORN, 2008, p. 299): Types of counts (ie, sponge, sharps, instruments, miscellaneous items) and number of counts taken; The names and titles of the surgical team members performing the counts; Figure 10.2 X-ray showing a retained radiopaque sponge.
Chapter 10: Perform Sponge, Sharp, and Instrument Counts 289 The results of the counts; Notification of the surgeon; Any instruments or sponges intentionally remaining with the patient; Actions taken in the event of discrepancies; Outcomes of actions taken; The rationale for not performing or finishing counts as outlined in policy. The registered nurse circulator, as the responsible person, and the scrub person should sign the patient record as prescribed by the facility s policy. CONCLUSION Legislation does not require sponge, sharp, and instrument counts be performed, nor does legislation identify those who should do the counts. The law does require, however, that members of the surgical team do not negligently leave foreign bodies in patients. Follow the steps listed in this chapter and review the current AORN Recommended Practices for Sponge, Sharp, and Instrument Counts. In doing so, you will greatly reduce the patient s risk for retained foreign bodies after an operative or invasive procedure. The surgical team members should view counts from the interdisciplinary perspective and collaborate in writing and follow sensible and safe count policies and procedures (AORN, 2008, p. 299). COMPETENCY ASSESSMENT Perform Sponge, Sharp, and Instrument Counts Name: Title: Unit: Date of Validation: Type of Validation: Initial Annual Bi-annual COMPETENCY STATEMENT: The nurse demonstrates competency to perform sponge, sharps, and instrument counts during the operative or invasive procedure. Performance Criteria Met Not Met 1. Identifies the patient s risk for adverse outcomes related to the retention of extraneous objects 2. Initiates count procedures that reduce the patient s risk for retained extraneous objects 3. Initiates incorrect count procedures 4. Documents count procedures according to facility policy 10 Validator s Signature Employee s Signature Validator s Printed Name
290 Section 2: Competencies for Safe Patient Care REFERENCES 1. Association of perioperative Registered Nurses. Recommended practices for sponge, sharp, and instrument counts. Perioperative Standards and Recommended Practices. Denver: AORN, Inc, 2008: pp. 293 302. 2. Murphy, E.K. (1991). OR nursing law: Counts, documentation revisited. AORN Journal; 54(4): p. 878. 3. Murphy, E.K. (2004). OR nursing law: Protecting patients from potential injuries. AORN Journal; 79(5): pp. 1014 1015. 4. PNDS. Extraneous objects. Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. Denver; AORN, Inc, 2007: pp. 31 37. 5. The conceptual framework of the PNDS. In Perioperative Nursing Data Set; the Perioperative Nursing Vocabulary: (Denver: AORN, Inc, 2007), 19, 25.