Reducing Surgical Instrument Count Errors

Healthcare Human Factors


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 to have a nurse 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, nursing educators from the University Health Network (UHN) approached Healthcare Human Factors 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 decided to redesign UHN’s Surgical Instrument Count Sheets that were used for documenting and verifying counts. The redesigned count sheet was less cluttered, easier to read and was service-specific such that unused sections may 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.