Reducing surgical instrument count errors through the redesign of Instrument Count Sheets

January 2010 to May 2010


Errors in the operating room can have serious consequences for patients. In particular, the problem of retained foreign objects (i.e., leaving a sponge, instrument or other surgical item inside the patient) can result in serious patient injury. To reduce the risk of retained foreign objects, the current practice is for nurses to meticulously count each item/instrument introduced and removed from the sterile field throughout the surgical procedure. As a result, the counting process itself is highly susceptible to human error. Furthermore, count discrepancies are disruptive to case progression and may cause significant delays.
In view of this problem, UHN nursing educators approached HTSRT for assistance.

Over a period of two months, the team conducted extensive ethnographic observations within the operating room to understand the current counting practice and the interactions between surgical team members. Based on the observations, a number of potential count errors and underlying causes were identified. To address some of the issues, the team redesigned UHN’s Surgical Instrument Count Sheets to be less cluttered and easier to read. New sheets were also service-specific such that unused sections could easily be removed.

Pilot testing sessions were conducted with a number of surgical teams using the redesigned count sheet. Overall, it was very well received, and feedback from nurses led to further refinement of the count sheets.

Funding Agency

University Health Network

Project Team

Rachel White
Varuna Prakhash (student)
Karen Kan (student)