Incorrect Surgical Counts Risk Factors

This essay discusses the risk factors and causes of incorrect surgical counts and their impact on patient safety. It explores best practices, policies, and recommendations to prevent the retention of surgical items. The author reflects on their own experience as a scrub nurse and presents an action plan to improve perioperative practice.

Incorrect surgical counts risk factors
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Sadaf Naveed

Introduction
‘Operating theatres are dynamic environments that require multiple professional team
interactions. Effective teamwork is essential for the efficient delivery of safe patient care'
(Wilson & Farooq 2018: 188). The perioperative practitioner/scrub nurse plays an important
role in maintaining a theatre environment safe for patients and work as a patient's advocate
(Nursing & Midwifery Council (NMC), 2015). One of the primary roles of the scrub nurse is
to ensure that surgical counts are done correctly and to protect patients from retention of
unintended surgical items (Association of Perioperative Registered Nurses (AORN), 2015).
The perioperative surgical counts are crucial and play an important part in promoting the
surgical patient’s safety. It is serious and classified as ‘never event’ when surgical items
remained in the wound unintentionally (Department of Health (DOH), 2013), considered an
unacceptable and preventable error with the requirement to report to The Joint Commission
as a sentinel event since 2013 (Hariharan and Lobo, 2013; Norton, 2014; Goldberg &
Feldman, 2012).
Objectives
The author of this essay is a qualified staff nurse who has worked in theatres for one year as a
scrub nurse. The scrub nurse will be reflecting upon her own experience. In this assignment,
the fundamental reasons (such as human factors) will be explored. The reason surgical counts
procedure and related protocols fail in practice will be discussed. Key findings around
national and local standards and policies will be critically discussed. The essay will analyze
risk factors and interprofessional issues related to the scrub nurse role associated with the
retained surgical items. The author will explore the implications of why surgical items counts
are not done properly and why best practice not been followed. Finally, an action plan will be
presented to improve perioperative practice by training staff and keeping them up to date with
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local and national guidelines related to surgical counts and to effectively implement best
practice.
Policies, Recommendations and best practice in relation to surgical counts
The World Health Organisation (WHO) (2008) started a campaign "Safe Surgery Saves
Lives" in this there were ten objectives and among these, there was an essential to ensure
surgical safety, by preventing retention of surgical items in surgical wounds. Surgical counts
are a manual process to count surgical items such as instruments, swabs, needles, etc used in
the sterile field during surgeries between two theatre personnel, one of whom must be
registered perioperative practitioner (Association for Perioperative Practice (AFP) (2011).
The WHO (2009) recommends, as a guideline for patients’ safety, the undertaking of the
counting process in every surgery and indicates the need for counting all surgical items used
in the sterile field. Instruments must be standardized and listed. It should be in the operating
department policy to specify all surgical items should be counted and recorded during the
counting procedure (AFPP, 2007). To maintain patient safety and prevent the risk of
accidental retention of surgical items the scrub nurse must count all the recordable items for
both major and minor cases. The scrub nurse follows the policy for when the counts should
take place; such as all surgical recordable items must be counted before the start of surgical
procedure, when scrub nurse receive any extra items during the procedure, at the closure of
body cavity such as sternum closure during cardiac surgery, at the start of wound closure,
every skin layer closure and following completion of the procedure. It is a scrub practitioner's
professional responsibility to adhere to policy (AORN, 2013).
The instrument count is recorded by the circulatory practitioner on the tray sheets provided
by the sterilization department within the packs. Swabs, needles, and sharps, etc are recorded
on the whiteboard by circulatory practitioners which is visible to scrub nurse (Goodman and
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Spry, 2014). All the whiteboard items are also documented on theatre care plan which stays
in patient's notes. For instruments which come in several parts, it is the scrub nurse’s
responsibility to check that all instruments are complete, there is no part is missing and it is in
working condition before use (Wicker and Dalby, 2016). It is the duty of scrub to count aloud
and record all surgical items together with the circulatory practitioner (AORN, 2013). If
during or at the end of the procedure the counts are incorrect, it is scrub nurse responsibility
is to inform the surgeon immediately (AFPP, 2011., Wicker and O’Neil, 2010).
It is important that staff follow the National Safety Standards for Invasive Procedures (Nat
SSIPs) (2015) or Local standards for invasive procedures (LocSSIPs). The NatSSIPs (2015)
was authorized by NHS England. The aim of this document is to promote patient safety by
reducing the number of safety incidents for the patient undergoing invasive procedures and to
prevent ‘Never Events’. NatSSIPs (2015), using existing frameworks such as WHO checklist,
teamwork, and human factors produce its principles for healthcare professionals to implement
best practice and deliver safe patient care. This includes standardized WHO safety checklist,
which is designed to improve communication and teamwork between theatres surgical team.
It also promotes staff education and training. To recognize human factors and prevent Never
Events occurring.
NMC (2015) and Health and Care Professions Council (HCPC) (2016), state that the
registered practitioners are accountable for their own conduct, their actions, and omissions in
practice. The scrub nurse must have knowledge and understanding, and this includes legal
knowledge and must be aware of the limits that the law imposes on her or the power it gives
her, been unaware or ignoring the law can’t defend the practitioners (Dimond, 2015).
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Jones (2018) identifies the importance of performing the 5 steps/ WHO checklist, finding that
using the checklist effectively can empower all the surgical team including scrub nurse/
practitioners and if there is any discrepancy in the surgical count, it gives them chance to
voice out. If scrub nurse carries out false count or omission or fails to inform surgeon and
team about the incorrect count, that can lead scrub nurse at risk of been charged for
negligence (Beesley & Pirie, 2005, HCPC, 2016 and NMC, 2015, Donnelly 2014).
The local policy within the author's trust is for surgeons to visual check the cavity before
starting closure of the wound, but the author experienced that not every surgeon is compliant
with this policy. It is possible that surgeons might misunderstand the purpose of the policy
and set standards or feel burdened by this unnecessary information (Anne & Irving 2014). If
surgical items are missing and counts is incorrect it is ultimately the surgeon’s responsibility
is to decide what to do about missing item, such as whether to continue with wound closure
or order an x-ray before closure, however it still lies scrub nurse responsibility to document
all the details in care plan to protect her/his self from lawsuits.
The surgeon is required to involve the surgical team to complete the ‘sign out' and debrief.
The ‘sign out' section of the WHO (2009) surgical checklist confirms that all counts are
correct and items accounted for (National Patient Safety Agency (NPSA), 2009). The debrief
at the end of the list gives the opportunity to discuss if the surgical staff work well together as
a team, to highlight things that worked and concerns surgical team members might have and
how it can be improved (Wicker and Dalby, 2015).
A major benefit of the ‘sign out' as well as making sure the correct procedure has been
performed and confirming correct surgical counts, is that it empowers and values all surgical
team involvement. It improves communication between surgical team members and increases
patient's safety (Treadwell, et al. 2014).
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After surgery, the scrub nurse/ practitioner needs to complete documentation and write details
about the surgery and update the computer (Wicker and Dalby, 2017). The circulatory
practitioners also sign their names in the theatre care plan to accept accountability for the
surgical count procedure (Phillips, 2017). If there are missing items it is scrub nurse
responsibility to document in theatre register, in the patient’s care plan and complete an
incident reporting form. At the end of every case all the items get removed from theatre, all
bins are changed to new ones, this is to help prevent errors occurring in future counts (Wicker
and O’Neil, 2010).
However, when the final counts are done correctly without any deficient, there is still a
chance that surgical items may be retained in unintentionally (Rowlands, 2012). The author is
aware of an incident ‘never event' where surgeon unintentionally left the surgical item in the
patient's chest. All the counts were correct as this item wasn't part of surgical count and it was
unexpected that it would remain inside the patient. When the surgeon realized what had
happened the patient was returned to theatre and the surgical item was removed. After the
event, the item was added to the count list and became scrub practitioner's responsibility to
confirm with circulatory practitioners during the surgery its removal and documentation on
the whiteboard and patient care plan. Because of this incident, many other items were also
added to the count list such as Liga clips, syringes, etc
Impact of retained items and potential cause
Despite advances in the prevention of retention of foreign bodies; it still occurs which causes
physical, emotional and financial damages for patients (Rowlands, 2012; Steelman et, al.
2015). The consequence of these errors can often result in lawsuit or litigation (Woodhead,
2005; WHO, 2009). This increases costs of healthcare services by delaying discharge and
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requirement of extra treatments. (Stawicki et al., 2013; Steelman et al., 2015). The causes of
unintentional surgical items may be infection, loss of function/ limbs, bleeding, slow wound
healing, stress for patients due to worrying about future consequences, unnecessary pain or
even death (Hariharan et al., 2013; Norton et al., 2012; Norton, 2014; AORN, 2016).
There is also a possibility that patients may also claim that the surgical team not been
adherence to their code of conduct and been negligent. Furthermore, the patient can claim for
their loss of earning, pain, psychological and physiological stress and inconvenience that has
been caused. These claims may be against the hospital directly, or with the surgical team that
has been involved in the error that has occurred (Wicker & O’Neil, 2010).
The major cause of errors and incidents ‘Never Events' are due to both human and
environmental factors. Basically, human factors are anything that affects individual
performance (Ives and Hillier, 2015). Furthermore, Rowlands (2012) states the factors that
increase risks associated with incorrect surgical counts are: patient with high body mass
index (BMI), increase demands on scrub practitioners, unplanned surgical intervention,
communication difficulties, emergency procedures, lack of standardized in count process and
procedures with multiple surgical teams, long procedure duration, procedure where no
surgical counts are performed and procedure that results in an incorrect surgical count.
There is often an expectation for scrub nurses to perform a dual role as both scrub nurse and
surgical first assistant which can cause surgical count discrepancy. The risk is increased
because scrub nurses might feel pressured and find hard to concentrate completely on all the
tasks they are required to perform The scrub nurse might not have appropriate training to
perform the dual role, or not competent to do so. All of these are human factors. It is
important that nurses remember their duty of care owed to the patient (PCC, 2018; NMC
2015).
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The scrub nurse should be aware of her own limitation and understand that by performing the
dual role the scrub nurse will be unable to deliver safe patient care. The author has witnessed
that scrubbed nurses appear ‘to act willingly in a dual role regardless of the legal and
professional accountability and therefore lay open to criticism' (Tanner, 2002: 67).
Perioperative Care Collaborative (2018) state that if a scrub nurse is required to perform a
dual role, a policy from the trust should be in place to support this practice and full risk
assessment should be done to ensure patient safety. The registered practitioners must not
perform a dual role if they are in doubt or policy does not support their actions.
Other causes of retention of surgical items are; ritualism, as counts become everyday task and
staff don't concentrate while counts were taking place, general chaos such as loud music, rush
to perioperative preparation, and communication barriers (Waring et al., 2007; Rowlands and
Steeves, 2010).
Non-compliant behaviors during surgical counts can be because of lack of knowledge and
awareness of professional standards and local hospital policies as well as lack of respect for
others (Rowlands & Steeves, 2010). Sometimes practitioners find it hard or due to lack of
scrub experience has the inability to maintain a tidy work area and inconsistency regarding
counting methods for some equipment (Rowlands & Steeves, 2010). This could be due to
lack of experience or staff not been trained adequately to perform the role.
The author has witnessed incidents where the surgical team are disrespectful towards each
other. Some staff don't pay attention or visually look when surgical counts are taking place
and just ticked boxes, unless been told and scrub nurse stresses them to visually look and
make sure that all surgical items they are ticking for are there and explain the importance of
it. Lack of confidence in scrub nurse to challenge bad behaviors can also be a cause of
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incorrect surgical counts. (Norton et al., 2012; Rowland & Steeves 2010; Norton, 2014;
Goldberg and Feldman, 2012).
Another influence on incorrect surgical counts is a noisy environment. Sometimes the
atmosphere appears chaotic in theatres when everyone bombards the scrub nurse such as
surgeon is asking for instruments, perfusionist setting up for the patient to go on cell saver,
the circulatory staff starts tiding up and start asking for instrument sets during final counts.
The author has found that it is only a scrub nurse responsibility without any team member
supporting her to do counts safely. (Norton et al., 2012; Rowland & Steeves, 2010; Norton
2014; Goldberg and Feldman, 2012). This poor communication and barriers to effective
communication are related to human factors which can interfere with team effectiveness and
safer patient care (Norton et al., 2012; Rowland & Steeves, 2010; Norton 2014; Goldberg and
Feldman, 2012).
According to Carayon (2017), Stress, fatigue cognitive, workload, design, equipment, teams,
and culture are the most important seven key factors in healthcare. It is important to have
awareness about human factors to minimize them and create safer, effective and patient
center ways of working, as they are signs where errors occur. The problems that relate to
human factors are rapid turnover in team members, personnel who rushed for time,
withholding important information that can affect patient care delivery, pecking order,
defensive behaviours and insecurity, laziness, conflict between team member, lack of clarity
and misunderstanding and lack of knowledge and skills which require the practitioners to do
the job (Phillips, 2017).
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Action Plan
Goal
To perform surgical counts effectively and efficiently, to deliver safe, high-quality patient
center care and to achieve 100% correct surgical counts. The scrub nurse needs to ensure that
change is permanent.
Rationale and change method
This change needs to be implanted because patients deserve reliable processes and ‘Never
Events’ are unacceptable and can be avoided. The surgical team needs to work together, each
member needs to take accountability and come away from blaming culture.
To ensure the change is effective local standards, policies and protocols must be created or
revised. To improve the surgical count process in the theatres the author recommends
implementing ‘red rules' and using the NMC code of professional conduct to impower scrub
nurses/ practitioners (Rowlands, 2012). Implementing red rules will foster high standards of
care and safety culture behaviors. Scharf (2007;1) suggests ‘one error- reduction strategy in
safety culture is to use red rules, which were initially used in the nuclear power industry as
standards that should be undertaken every time in a particular process, except in rare or
urgent situations'.
Red rules also need to be implemented to decrease distraction and occurrences of incorrect
surgical counts, by keeping noise lower in theatres such as staff talking, loud music, etc. The
scrub nurse discussed implementing red rules in staff meeting under manager supervision.
World Health Organisation (2009), safety checklist is a tool that improves surgical teamwork,
encourages good communication, maintains patient safety and promote leadership.
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For my action plan, I will be using the three- stages model of planned changed which was
developed by a psychologist Lewin in 1940 and S.M.A.R.T action plan by Doran, (1981).
These are the most useful framework in this area which has been using since when change
implementation is required.
The scrub nurse will unfreeze the way the surgical team works and bring improvement when
performing surgical counts and fulfilling WHO checklists. To improve communication
between surgical team the scrub takes responsibility and engage directly with the surgical
team, ward manager and practice-based educator to agree to priority changes to be made to
improve the overall surgical count's process which involves improving staff knowledge and
skills within the surgical team.
As part of the unfreezing element of change, staff training will be delivered during theatre
team meetings to update local and national policies and standards and will be repeated
regularly to increase and confirm awareness. Staff training while on the floor also needs to
improve while performing surgical counts, therefore assessors will be selected who will make
sure that the change has been implemented and the surgical team is compliant with safe
practice.
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The scrub nurse and with her other surgical team started to promote the WHO safety list tool
in theatre and it was stressed every day that it should be done properly according to local
policy and standards. It has helped staff to be aware of patient condition the procedure that
needs to be done, understanding of patient’s needs and empowering staff
An audit will be conducted for 3 weeks before and six months after the changes are
implemented to make sure all staff is following local and national policies while conducting
the surgical counts.
For implementing an audit, the scrub nurse required ward manager and practice-based
educator help. This will be a great opportunity for the scrub nurse to develop skills to perform
audits. The goal of the audit is to investigate if the surgical team in compliance with national
and local policies and guidelines which is formed by a professional organization for when the
surgical counts are performed (AFPP, 2012; AORN, 2012).
After the change has been implemented the good practice needs to refreeze and become
permanent. It is ongoing that every surgical team needs to maintain good practice whether its
communication between surgical team or completing the WHO checklist or counting surgical
items. Teamwork plays an important part when it comes to doing surgical counts. It is
important for safer surgery that open communication between the surgical team should be
encouraged, patient safety should be put forefront of everything that the team does.
Conclusion
The surgical team should give each other the opportunity to raise a concern or address
potential safety issues. Research has shown that major cause of error occurring is often not
the failing of an individual but chain of circumstances which makes error probable or
inevitable, therefore teamwork and vigilance are essential to maintain a safe environment for
patient and deliver safe care. Any never events, incidents that have occurred should be
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reported on hospital incident reporting system, not to blame individual, so that lessons can be
learned to prevent such incidents from possible reoccurrence and causing harm to another
patient (DOH, 2011). There should be minimum noise in theatre, surgeons should allow time
for scrub nurses to perform surgical count and there should be no interruption. WHO safety
surgical should be completed properly and all team should take part in it. Red rules should be
promoted by managers and theatre co-ordinators. The scrub staff should have legal
knowledge and awareness of the law. It is important to consider human factors in everything
that been done in theatres because it is a surgical team responsibility to maintain patient
safety. ‘People working in health care are among the most educated and dedicated workforce
in any industry. The problem is not bad people; the problem is that the system needs to be
made safer' (Woodhead, 2009: 358).
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