Patients Count on It: An Initiativeto Reduce Incorrect Counts andPrevent Retained Surgical ItemsELIZABETH K. NORTON, BSN, RN, CNOR; CORNELIA MARTIN, RN, CNOR;ANNE J. MICHELI, MS, RN, NEA-BC

ABSTRACT

Retained surgical items were the most frequently reported sentinel event in 2010,according to The Joint Commission. Perioperative nurse leaders at Children’s Hos-pital Boston, a pediatric teaching hospital, conducted a quality improvement initia-tive to reduce or eliminate incorrect counts and count discrepancies, which increasethe risk of an item being unintentionally retained after surgery. Work includededucating the perioperative staff members, standardizing count practices, formallyreviewing every reported count discrepancy with the nursing team, and reviewingand revising the count policy for prevention of retained surgical items. The initiativereduced the number of incorrect counts and count discrepancies by 50% between2009 to 2010. These initiatives continue to be expanded, and the results have beensustained on an ongoing basis. AORN J 95 (January 2012) 109-121. © AORN, Inc,2012. doi: 10.1016/j.aorn.2011.06.007

Key words: retained surgical items, count discrepancies, incorrect counts.

Incorrect counts, as well as count discrepan-cies, may lead to the unintentional retention ofa surgical item after surgery, which may cause

serious harm to the patient.1 One report suggeststhat retained surgical items (RSIs) are 100 timesmore likely to occur in procedures in which thereis a count discrepancy.2 Prevention of RSIs hasbeen identified by AORN, the American Collegeof Surgeons (ACS), and The Joint Commission asa national patient safety priority.

In accordance with national initiatives, periop-erative nurse leaders at Children’s Hospital Bos-ton, Massachusetts, conducted an OR quality im-provement (QI) initiative to reduce incorrectcounts and count discrepancies. This project

included conducting extensive staff education,standardizing count practices, reviewing all re-ported count discrepancies, and revising thecounts policy at Children’s Hospital Boston. Theresults of this initiative surpassed our initial ob-jective. Not only did we reduce the number ofreported incorrect counts and count discrepancies,but we also improved the entire count process.

LITERATURE REVIEWAn RSI is a sentinel event, which is defined as“any unexpected occurrence involving death orserious physical or psychological injury or riskthereof.”3 Accredited hospitals may elect to reportRSIs to The Joint Commission; however, the

doi: 10.1016/j.aorn.2011.06.007

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occurrence of sentinel events might also be madeknown through reporting in the newspaper, pa-tient complaints, or reports to the state. Require-ments for mandated reporting to regulatory bodiesvary from state to state.

Retained surgical items resulting in death orpermanent loss of function were identified byThe Joint Commission as the most frequentlyreported sentinel event in 2010 through the sec-ond quarter of 2011.4 Retained surgical itemssurpassed wrong patient, wrong site, and/orwrong procedure events, which were the mostfrequently reported events in 2008 and 2009(Figures 1 and 2). The Joint Commission ana-lyzed all sentinel events reported from 1995 to2005 and found that miscommunication was themain contributing factor.4

Researchers have identified varying risk factorsthat lead to RSIs. For example, Rowlands and

Steeves5 conducted a qualitative analysis on in-correct surgical counts and discovered three com-mon themes that represented challenges: bad be-havior, general chaos, and communicationdifficulties. Bad behavior included “sloppy indi-viduals, inconsistencies, lack of adherence, and norespect.”5(p413) General chaos included disruptiveactivities such as loud music or excessive talkingduring critical moments of the count process,lack of a standardized orientation program, andassignment of inexperienced staff members to asurgical procedure. Communication difficultiesincluded chatter that interferes with full atten-tion to the surgical count, eroding collaborationwithin the surgical team, a rushed feeling dur-ing the counting process, and omission of criti-cal information (eg, sponges intentionallypacked in the surgical wound) during staffmember hand offs.5

Figure 1. Joint Commission most frequently reviewed sentinel event categories by year. © The JointCommission, 2011. Reprinted with permission.

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Gawande et al6 found that the risk of an RSIsignificantly increases in emergency surgery,when there are unexpected changes in the sur-gical procedure, in patients who have a higherbody mass index, and when there is a break-down in communication. Lincourt et al7 notedan association between RSIs and multiple majorsurgical procedures performed simultaneouslyon a patient and an incorrect instrument orsponge count.

Camp et al8 examined the risk factors and out-comes associated with RSIs during surgery inchildren based on the Agency for Healthcare Re-search and Quality Pediatric Quality Indicators,which are designed to evaluate the quality andsafety of pediatric care. The researchers con-ducted a case-control study that analyzed the Pe-diatric Quality Indicators database and reviewed

413 incidents of unintentional RSIs after1,946,831 surgical procedures. The researchersconcluded that the highest likelihood of RSIs un-intentionally left behind after surgery occurredduring gynecologic procedures. The study alsoshowed that the RSIs were associated with alength of stay eight days longer than the normand a $35,681 increase in total hospital chargescompared with usual costs. However, mortalityrates did not increase.8

Patients with an RSI (eg, instrument,sponge) can experience complications such aspain, infection, abscess, or intestinal obstruc-tion.9 Berger and Sanders10 reported on datafrom a closed claims study (1985-2001) thatpatient deaths were rare events, but they dididentify some common adverse outcomes re-lated to RSIs:

Figure 2. Unintended retention of foreign object events reviewed by The Joint Commission (resulting in deathor permanent loss of function). © The Joint Commission, 2011. Reprinted with permission.

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! 59% of patients had readmission to the hospi-tal or a prolonged length of stay,

! 69% had a second surgery to remove the re-tained object,

! 50% had sepsis or infection,! 15% had a fistula or small bowel obstruction,

and! 7% had a visceral perforation.

In another study, retained instruments were mostcommonly discovered around the 21st day after asurgical procedure, and only 6% were discoveredwithin one day of the surgical procedure. SomeRSIs were not discovered until several months oreven years later.6

The actual incidence of RSIs is unclear; how-ever, estimates range from one in every 1,000to 1,500 abdominal procedures to one in every8,000 to 18,000 inpatient procedures annuallyin the United States.11 Surgical items are mostcommonly retained in the abdominal cavity andthorax, although no body cavity is exempt.7

Mortality rates in the United States from unin-tended RSIs have been estimated to be as highas 35%.12

Cost and Legal RamificationsThe cost of RSIs can be significant, as they maylead to patient harm, increased hospital stays, andlitigation. The surgical team is subject to malprac-tice lawsuits and actions from the National Practi-tioner Data Bank and state licensing board whensurgical items are retained.9 The National Practi-tioner Data Bank monitors the occurrence of med-ical malpractice and disciplines incompetent clini-cians with the goal of improving health carequality.9 The Centers for Medicare & MedicaidServices13 has calculated a cost of approximately$166,135 for each undetected RSI, which includeslegal defense, indemnity payments, and unreim-bursed surgical costs.1 In October 2008, the Cen-ters for Medicare & Medicaid Services stoppedreimbursing health care facilities for postoperativecomplications related to RSIs.13

Standardizing Practice to PreventCount DiscrepanciesThe first line of defense in eliminating RSIs is asafe, thorough, and effective process of keepingtrack of sponges, instruments, needles, and othermiscellaneous items used in surgery and prevent-ing count discrepancies. Manual counting is de-pendent on human performance and environmen-tal factors that may affect subsequent recounts,which increases the chance for human error. Theliterature suggests that the most frequent reasonfor RSIs is human error caused by breakdown incommunication and faulty processes.14 Researchshows that communication breakdown, distrac-tions, competing demands, production pressure,and lack of significant personnel are all factorsthat can lead to counting errors.1 The OR culturealso can affect how the tasks are performed. Forexample, teams that encounter conflict, communi-cation breakdown, or barriers related to hierarchymay be more likely to follow incorrect or sub-standard counting practices.1,14

Inaccurate documentation of sponges and in-struments, which could potentially contribute toan RSI, was associated with the majority of dis-crepancies in one 2008 study.2 In this study, re-searchers used direct observation to prospectivelyevaluate and describe the rate and type of dis-crepancies that were encountered during thesurgical count. Results showed that one in eightsurgical procedures involved an intraoperativecount discrepancy. These findings represent thelimitations of manual surgical counts and dic-tate that discrepancies should always prompt athorough search and reconciliation process andshould never be ignored.

Adhering to a standardized count policy andpractice is one way to prevent the retention of asurgical item.1 AORN, the ACS, and The JointCommission promote and guide standardizedcount practices geared toward the prevention ofRSIs. The ACS14 has made several recommen-dations to prevent the retention of sponges,

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sharps, instruments, and other designated mis-cellaneous items:

! maintain an optimal OR environment to allowfocused performance of surgical tasks,

! consistently apply and adhere to standardizedcounting procedures,

! perform a methodical wound exploration be-fore closure of the surgical site,

! use x-ray detectable items in surgical wounds,and

! employ x-ray or other technology (eg, radio-frequency [RF] detection, bar coding), as indi-cated, to ensure no unintended item remains inthe surgical field.

The ACS recommends documenting the counteditems and any intentionally retained items (eg,packing), notifying the surgical team of thecount status, and documenting actions takenwhen a count discrepancy occurs. The ACSalso states that these measures can be sus-pended as necessary for any life-threateningsituations.14 Surgical facilities must provideresources to support these safety measures. Pol-icies and procedures for the prevention of RSIsshould be developed, reviewed, and revisedregularly.15

AORN, the ACS, and The Joint Commissionall have provided guidelines for the preventionof RSIs that were designed to accommodatevarious nursing practice settings. In most peri-operative settings, counting procedures are inplace to help prevent unintended RSIs and sub-sequent complications.9 However, regulationsdo not dictate how counts are to be performed.Most institutions develop their own policies andprocedures based on the recommended practiceguidelines from AORN and the ACS.15,16

Assistive TechnologyThe use of adjunct technology that aids teams inthe detection of a retained or missing sponge isgaining momentum, and the literature suggestsimplementing multiple methods of preven-tion.1,2,17,18 Strategies to consider include

radiograph screening, multidisciplinary ap-proaches, and the use of assistive technology.

Routine postoperative screening radiographshave been conducted at some hospitals. Gawandeet al6 recommended radiography at the end ofemergent surgeries, surgeries in which an unex-pected change in the procedure took place, andsurgeries on a patient with a high body mass in-dex. However, few studies have evaluated theeffectiveness of intraoperative and postoperativeradiographs.1 In one large study, 33% of RSIswere not detected on radiograph.11 The calculatedcost and the additional exposure to radiographyalso must be considered. Incorrect counts addtime to procedures, radiation exposure to patients,and the possibility of suboptimal film or failure tolocate the retained item.

Several studies of counts innovations have in-dicated a high rate of accuracy that surpasses theaccuracy of a traditional surgical count.2,19,20 Twotypes of adjunct technologies are currently avail-able: bar code and RF systems. Both systems areintended for use in addition to manual countingand are not intended to replace it. Neither ofthese systems currently can detect a retained in-strument or needle; however, surgical sponges arethe most commonly retained items.6 Use of tech-nology can facilitate recognition of a count dis-crepancy or detect a missing sponge, augment-ing the counting process even when the finalcount is considered correct. In fact, Gawande et al6

showed that 88% of RSIs were associated with acount that was thought to be correct. Assistivetechnologies have the potential to reduce hospitallitigation expenses, unreimbursed surgery, surgicaldelays, and exposure, as well as costs associatedwith using radiation.20 It is prudent for institu-tions to evaluate and consider implementing oneof these technologies to aid in the prevention ofretained surgical sponges.

Bar coding sponges tracks them by requiringeach sponge to be scanned onto the sterile fieldand scanned back off of the sterile field. Spongesmust be scanned one at a time and cannot be

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detected in bulk. In a randomized, controlledstudy, Greenberg et al2 discovered that bar codingdetected significantly more counting discrepanciesthan traditional manual counting protocols. Thesediscrepancies involved both misplaced sponges andmiscounted sponges. The researchers also found thatthe system introduced new technical difficulties andincreased the time spent counting. Bar coding im-proved the team’s ability to recognize count discrep-ancies but did not change the amount of time re-quired to resolve the discrepancy or decrease thelikelihood of requiring a radiograph to resolve thediscrepancy. In the event of an incorrect spongecount, a radiographic image will most likely betaken to rule out a retained sponge. By the end ofthe study, providers found the system to be easy touse, were confident in its ability to track spongesand detect miscounted or misplaced sponges, andreported having positive feelings about the countingprocess. Study results suggest that using bar-codedsponges has the potential to decrease the risk ofretained sponges.

Radio-frequency technology utilizes a tiny mi-crochip that is sewn into a gauze sponge and ahandheld wand that is connected to a self-calibrating console. This technology is intended tobe used at the end of a surgical procedure to vali-date count status, detect whether a sponge is re-tained in a patient, or help rectify an incorrectcount by detecting a missing sponge. In oneblinded, prospective, experimental trial, Macarioet al19 tested an RF wand device on eight patientswho were undergoing abdominal or pelvic sur-gery. Even though the sample size was small,they concluded that the RF wand device was100% accurate, and sponges were detected withinone minute. The researchers noted that despite theengineering success, the possibility of human er-ror and retained surgical sponges still exists be-cause scanning could be performed incorrectly,such as by the user holding the scanning devicetoo far away from the patient or not scanning thepatient’s entire body surface area. In addition, theresearchers gave a questionnaire to the surgeons

and nurses who were involved in the study; on ascale of 0% to 100%, they rated the system be-tween 85% and 93% for ease of use and 78% to94% for contributing to patient safety. A prospec-tive crossover study by Steelman18 determined100% sensitivity and specificity of RF technologyfor identification of retained surgical sponges in abroad range of participants. The participants en-rolled in the study had surgical sponges sequen-tially placed behind their torsos in the abdominalregion, and of the 210 participants, nearly halfwere morbidly obese. The researcher concludedthat this level of accuracy attained with RF tech-nology far outweighs manual counting or intraop-erative radiography and is therefore an appropri-ate tool to improve patient safety and preventretained sponges.18

Radio-frequency technology is available tosupport manual sponge counting, has been provenhighly accurate, and is cost effective. Children’sHospital Boston has invested in RF technologybecause it will not only detect a sponge in a pa-tient when counts are incorrect but, more impor-tantly, will detect a sponge when counts are con-sidered correct and human error has occurred.Count discrepancies occur regularly, and valuableOR time can be spent searching for a missingsponge; if it remains unresolved, the patient isexposed to radiation. The RF wand facilitatesfinding missing sponges and can improve effi-ciency and staff member satisfaction, decreaseexpensive OR time, prevent patient exposure toradiation, and avoid the cost of radiography. Itshould be used in addition to manual counting,even when counts are considered correct. Al-though the technology is easy to use, usersmust be trained to use the RF wand correctlyso that retained sponges can truly become“never events.”

QI INITIATIVEIn the spring of 2009, the OR director at Chil-dren’s Hospital Boston organized a perioperativenursing leadership retreat during which leadership

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group members were asked to identify periopera-tive nursing metric priorities that directly relatedto improved patient care and outcomes in theperioperative programs. Staff members agreedthat a QI initiative to reduce the number of incor-rect counts and count discrepancies and preventRSIs was a top priority.

The OR risk manager made perioperative nurs-ing staff members aware of the new initiative toreduce incorrect counts through staff meetingsand e-mails. Enthusiastic verbal and written feed-back received from nursing staff members sup-ported this endeavor, and this enthusiasm ulti-mately contributed to the success of the initiative.Recognizing the importance of this initiative, asmall task force developed a systematic strategythat included

! reviewing reported incorrect counts and countdiscrepancies,

! collaborating with the radiology department,! reviewing and revising the existing count

policy,! standardizing practice,! using a team approach to the count process,

and! conducting observational audits.

The goal was to reduce the number of reportedincorrect counts and count discrepancies and thusreduce patient exposure to radiographs, decrease

OR time and expense, and lower the risk of unin-tentional RSIs.

These strategies contributed to the reduction ofcount discrepancies in the main OR by 50% be-tween 2009 and 2010 (Figure 3). Additionally,there was an estimated OR cost savings of$12,500 associated with a decreased need for in-traoperative radiographs taken for unresolvedcounts (Figure 4). In 2009, there was one countdiscrepancy for every 367 surgeries, with noitems identified on radiograph. In 2010, there wasone count discrepancy for every 697 surgeries andone item, an instrument, found on radiographand removed in the OR before wound closure(Figure 5). Quality improvement strategies weredeveloped and refined throughout the year in2010. Implementation of standardized countpractices in the surgical suite has been at thecenter of these changes.

Review of Reported Incorrect Counts andCount DiscrepanciesThe electronic safety event reporting system thatwe use at Children’s Hospital Boston gathers dataon any adverse or near-miss events. Trends inincorrect counts led the OR risk manager to ana-lyze the data.

In 2010, the OR risk manager developed andimplemented a root cause analysis (RCA) tool togather information on incorrect counts. The OR risk

48 50

25

0102030405060

2008 2009 2010Year

Volume

Figure 3. Main OR Children’s Hospital Boston reported count discrepancies from 2008 to 2010. Note: Excludessatellite ORs and cardiac surgical services, which maintain separate data and have separate dedicatednursing staffs.

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manager followed up with the perioperative nursingteam on all procedures in which an incorrect countoccurred. The OR staff manager reviewed a sum-mary of the findings with the perioperative staffmembers who were involved and reinforced thecounts policy and practices as needed.

The RCA indicated that the majority of incor-rect counts involved needles. The RCA also re-vealed the following trends that contributed toincorrect counts:

! surgical procedures that lasted longer thaneight hours,

! multiple staff turnovers during a procedure,! documentation discrepancies or omissions of

items added to the surgical field,! communication breakdown, and

! a lack of standardized practice due to variabil-ity and interpretation of count policy.

The OR risk manager presented the overallfindings from the RCA during several staffmeetings, and these findings were recorded inthe meeting minutes. In addition, recommenda-tions were made to improve the process of howprocedures are assigned by limiting or reducingstaff turnover during procedures.

Collaboration With theRadiology DepartmentIncorrect counts add time to procedures, resultin radiation exposure to patients, and presentthe possibility of suboptimal film or failure tolocate the retained item. Children’s Hospital

$24,000 $25,000

$12,500

$0$5,000$10,000$15,000$20,000$25,000$30,000

2008 2009 2010Year

Figure 4. Main OR Children’s Hospital Boston radiology cost associated with count discrepancies from 2008 to2010.

1,000

1,200

1,400

1,600

1,800

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecMonth

Volume

2008 2009 2010

Figure 5. Main OR Children’s Hospital Boston procedure volume associated with count discrepancy from 2008 to2010.

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Boston follows AORN guidelines in the eventof a count discrepancy, which include conduct-ing a thorough examination of the surgical siteand field as well as a thorough search of theOR.15 In the event of an unresolved, incorrectcount, an x-ray is taken in the OR beforewound closure and is read simultaneously bythe surgeon and radiologist. The radiologistdocuments the final report in the patient record.

As part of the incorrect count follow-up, theOR risk manager reviewed the final radiologyreports for accuracy. She found that the “reasonfor the film” was frequently omitted or incor-rectly stated on the requisition. Therefore, whenstaff radiologists reviewed the final film, theywere not always aware of the actual itemdeemed missing. This concern led to collabora-tion with the radiologist-in-chief and the leadOR radiology technologist to improve processesrelated to incorrect counts. The OR radiologytechnologist and the perioperative nursing staffmembers were educated to accurately record the“reason for the film” on the requisition (eg,missing snap, missing 4 ! 4 sponge), therebyhelping to ensure that the final read would ruleout the indicated missing item. In addition, thelead OR radiology technologist trained his col-leagues to collaborate with the surgeon and en-sure that the radiological view of the surgicalsite(s) was adequate.

As part of the QI initiative, the OR risk man-ager worked with the lead OR radiology technolo-gist to label and radiograph commonly counteditems to demonstrate how the items appear onfilm, which would further enhance the accuracyof radiograph interpretation. These films are nowavailable in the radiology computer system, andthe images can be accessed by the surgeon orradiologist to review as needed.

Review and Revision of the Count PolicyThe hospital’s count policy was reviewed andrevised in July 2010 and again in January 2011based on 2010 AORN recommendations15 and

current literature, with input from the hospital’sOR practice committee members.21 Operatingroom managers, the OR nursing director, andthe OR governance committee members evalu-ated and approved policy updates and recom-mendations. After the policy updates were ap-proved, perioperative nurses reviewed theserevisions and updates through staff meetings,electronic education, and e-mail alerts. Key pol-icy updates included

! defining team roles and responsibilities,! requiring methodical wound exploration,! accounting for surgical items in their entirety

as they are passed back from the surgicalfield, and

! promoting active communication.

Standardized Count PracticesThe audit findings revealed a need to standard-ize the count process. After it was determinedthat nurses were documenting counts in variousways, a dry erase board was provided in eachOR to standardize counts. Count practice ex-pectations and updates were reinforced duringseveral educational inservice programs and staffmeetings and through electronic communica-tion. The nurse managers enforced the estab-lished protocol of having two nursing teammembers count audibly and visibly. Educationincluded the sequence of counting from the sur-gical field back to the Mayo stand, to the backtable, and then to the sponge receptacle.

Nurses in surgical specialties worked to-gether to streamline instrument kits in an effortto improve the instrument count process andremove obsolete and redundant items. Thenurses also updated the instrument count sheetsto facilitate a smooth flow during counting. Inaddition, the instrument count sheet and thestring of instruments were arranged in the sameorder for ease of counting. The updated count

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sheets list a total for each grouping of instru-ments. For example, all the scissors are listedindividually but the total number of scissorsalso is listed to improve efficiency.

Team ApproachIn 2011, Children’s Hospital Boston adopted ateam approach to the count process based onrecommendations from AORN, the ACS, andVerna C. Gibbs, MD, a nationally recognizedleader in the prevention of RSIs. Implementinga systematic multidisciplinary team approachsupported by a policy that meets recommendedpractices and the needs of the institution seemsto be a logical way to reduce the number ofRSIs and count discrepancies. In her 2010 pre-sentation “NoThing Left Behind®,”17 Dr Gibbsrecommended that surgeons take an active roleand “pause for the gauze.” This includes per-forming a methodical wound exploration in ev-ery procedure, actively looking for sponges,and announcing that sponges are removed. DrGibbs recommends a visible and transparentsystem that includes using pocketed spongeholders and dry erase boards for all team mem-bers to see. Use of a pocketed sponge holder isan inexpensive solution—they cost about 30cents each—to improve final accounting for allsponges. The sponges are placed in individualclear plastic pouches in quantities of 10 perholder. All sponges must be in the holder at theend of each procedure for the whole team tovisualize and verify during the final count. Thissystem provides the surgeon and nurse withproof that all the sponges have been removed.

Before wound closure, perioperative teammembers conduct a “wound closure time out”(Figure 6). This new process, which involves thewhole surgical team, begins before wound closurewith a member of the nursing team announcing,“wound closure time out.” During this process,the team members are expected to avoid interrup-tions or distractions. Relief of staff members dur-

ing the count process is prohibited. The surgeonis responsible for exploring the wound for anyunintentionally retained items. The nursingteam then completes the closing count by audi-bly and visibly conducting surgical counts. Thenursing team is responsible for announcing theclosing count status to the team. This process isembedded into the institution’s pediatric surgi-cal safety checklist in the “sign out” segment.After the wound closure time out is accom-plished, the team can proceed to conduct theremainder of the sign out or can complete thesign out after closure.22 The surgeon-in-chiefpresented this new process during mandatorymultidisciplinary grand rounds.

Figure 6. The wound closure time out is embeddedin the Pediatric Surgical Safety Checklist atChildren’s Hospital Boston in the “sign out”segment. Reprinted with permission.

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We implemented the use of RF technologyand the pocketed sponge holder system in Sep-tember 2011. Dedicated dry erase boards forcounting allow the whole team to view countsand have replaced paper count worksheets. Afinal count verification process includes theteam’s visualization and confirmation that allsponges are contained in the holder and there-fore not retained in the patient. Other new ini-tiatives for 2011 aimed at further improvingthe OR culture and safety to prevent RSIsinclude

! auditing the wound closure time-out process,! encouraging participation and accountability

from the entire surgical team,! reducing staff turnover during procedures,! reducing or eliminating staff turnover during

critical parts of procedures, and! discouraging interruptions after the counting

procedure is initiated until it is finished.

All of the new initiatives for 2011 have beenimplemented. We are measuring compliancethrough auditing.

Observational AuditsThe OR at Children’s Hospital Boston hasan active measurement committee that isdevoted to improving compliance through theaudit process. We developed a live audit tool tocollect data on count practices. The OR auditcommittee members areresponsible for monitoringcompliance with thefollowing:

! standardized count process;! use of dry erase boards

for visualization of countdocumentation for allprocedures;

! the initial instrumentcount for all laparo-scopic, thoracoscopic,and robotic procedures;

! the initial instrument count for abdominal,retroperitoneal, and thoracic cavity surgery;

! change over count during permanent relief;! counting of miscellaneous and disposable

items; and! withholding of dressing sponges until after the

final count.

The observational count audits began in 2010.Results identified some areas that were in need ofimprovement, including discrepancies in interpre-tation of standardized count practices (ie, the se-quence of counting from the surgical field back tothe sponge receptacle). The auditors discovered awide variation in the type of worksheets used totally intraoperative counts (eg, whiteboard, countsheet, sheet of unmarked paper). These disparitiescontributed to incorrect counts and count discrep-ancies associated with documentation errors. Au-ditors also noted that staff members did not con-sistently include disposable instruments in thecount. On the positive side, the auditors observedminimal distractions such as conversations, loudmusic, beepers, and telephone calls during thecount process, and compliance with counting in-struments was 100%. Audit results are sharedwith the nursing staff members, and when thresh-olds are met, the audit tool is revised. The mea-surement committee continues to observe variousaspects of count practices.

AORN Resources

! AORN Video Library: Preventing Retained Surgical Items(Ciné-Med, 2011). http://cine-med.com/index.php?nav"aorn.

! Clinical Answers: Counts/Retained Surgical Items. http://www.aorn.org/Clinical_Practice/Clinical_Answers/Clinical_Answers.aspx.

! Confidence-Based Learning module: Prevention of retainedsurgical items. http://www.aorn.org/Education/Curriculum/Confidence_Based_Learning/Retained_Surgical_Items.aspx.

Web site access verified December 13, 2011.

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CONCLUSIONThe goal of this QI project was to reduce thenumber of incorrect counts and count discrep-ancies and to prevent RSIs. Standardized countpractice, policy updates, staff education, andenhanced collaboration with physician col-leagues led to a 50% reduction in reported in-correct counts in 2010. Staff members at Chil-dren’s Hospital Boston are committed to thisongoing and evolving QI process. These initia-tives, with the adoption of adjunct technology,will optimize the goal of preventing RSIs. Re-tained surgical items are preventable “neverevents,” and perioperative nurses play a vitalrole in ensuring that “never” becomesreality.

Acknowledgement: The authors thank the ORnursing/SST staff members at Children’s HospitalBoston for collaborating and participating in thisquality improvement initiative to improve ourcount process for the prevention of retained sur-gical items.

Editor’s note: NoThing Left Behind is a regis-tered trademark of Verna C. Gibbs, San Fran-cisco, CA.

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13. Hospital-acquired conditions (present on admission in-dicator). Centers for Medicare & Medicaid Services.http://www.cms.gov/HospitalAcqCond. Accessed Sep-tember 16, 2011.

14. Gibbs VC, McGrath MH, Russell TR. The preventionof retained foreign bodies after surgery. Bull Am CollSurg. 2005;90(10):12-14, 56.

15. Recommended practices for prevention of retained sur-gical items. In: Perioperative Standards and Recom-mended Practices. Denver, CO: AORN, Inc; 2011:263-282.

16. [ST-51] Statement on the prevention of retained foreignbodies after surgery. Chicago, IL: American College ofSurgeons; 2005. http://www.facs.org/fellows_info/statements/st-51.html. Accessed October 6, 2011.

17. Gibbs VC. NoThing left behind®: A National SurgicalPatient-Safety Project to prevent retained surgical items.Talk presented at: Children’s Hospital Corporation ofAmerica; 2010; Kansas City, MO.

18. Steelman VM. Sensitivity of detection of radiofre-quency surgical sponges: a prospective, cross-overstudy. Am J Surg. 2011;201(2):233-237.

19. Macario A, Morris D, Morris S. Initial clinical evalua-tion of a handheld device for detecting retained surgicalgauze sponges using radiofrequency identification tech-nology. Arch Surg. 2006;141(7):659-662.

20. DiConsigio J. Count on a backup. Mater Manag HealthCare. 2008;17(11):18-21.

21. Norton EK, Micheli AJ, Gedney J, Felkerson T. Anursing led collaborative approach for the developmentand implementation of a count policy for the preventionof retained surgical items. AORN J. In press.

22. Norton EK, Rangel SJ. Implementing a pediatric surgi-cal safety checklist in the OR and beyond. AORN J.2010;92(1):61-71.

January 2012 Vol 95 No 1 NORTON—MARTIN—MICHELI

120 AORN Journal

Elizabeth K. Norton, BSN, RN, CNOR, is alevel III staff nurse and OR patient safetyand quality nurse at Children’s Hospital Bos-ton, MA. Ms Norton has no declared affilia-tion that could be perceived as posing a po-tential conflict of interest in the publicationof this article.

Cornelia Martin, RN, CNOR, is a level IIIstaff nurse, OR Risk Management, at Chil-dren’s Hospital Boston, MA. Ms Martin has no

declared affiliation that could be perceived asposing a potential conflict of interest in thepublication of this article.

Anne J. Micheli, MS, RN, NEA-BC, is thedirector of perioperative and allied programs,Nursing/Patient Services, Children’s HospitalBoston, MA. Ms Micheli has no declared affil-iation that could be perceived as posing a po-tential conflict of interest in the publication ofthis article.

The AORN Foundation—Promoting Patient Safety

Perioperative nurses are at the forefront of patient safety and the AORN Foundation iscommitted to supporting their role in making surgery safe for every patient.

Since 1991, the AORN Foundation has provided funding for:

f academic scholarships,

f research and education grants,

f conference scholarships, and

f patient safety resources.

Donations are essential to ensuring that the work of the Foundation continues. To make acontribution, visit www.aorn.org/AORNFoundation or call (800) 755-2676 x 230. You can

also send your donation to 2170 S Parker Road, Suite 400, Denver, CO 80231.

Thank you for “Supporting the Nurses Who Make Surgery Safe.”

AN INITIATIVE TO PREVENT RETAINED SURGICAL ITEMS www.aornjournal.org

AORN Journal 121