Recommended practices for sponge, sharps, and instrument counts

AORN Journal, Feb, 2006

The following recommended practices ere developed by the AORN Recomended Practices Committee and have been approved by the AORN Board of Directors. They were presented as proposed recommended practices for comments by members and others. They are effective Jan 1, 2006.

These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be implemented.

AORN recognizes the numerous settings in which perioperative nurses practice. These recommended practices are intended as guidelines that are adaptable to various practice settings. These practice settings include traditional operating rooms, ambulatory surgery centers, physicians' offices, cardiac catheterization suites, endoscopy suites, radiology departments, and all other areas where operative and other invasive procedures may be performed.

PURPOSE. These recommended practices provide guidance to perioperative registered nurses in performing sponge, sharp, and instrument counts in their practice settings. Counts are performed to account for all items and to lessen the potential for injury to the patient as a result of a retained foreign body. The expected outcome of primary importance to this recommended practice is outcome 02, "The patient is free from signs and symptoms of injury due to extraneous objects." (1) Complete and accurate counting procedures help promote optimal perioperative patient outcomes and demonstrate the perioperative practitioner's commitment to patient safety.

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. (2) The doctrine of res ipsa loquitur (ie, "the thing speaks for itself") is most applicable in cases involving retained foreign objects, rendering those litigations nearly indefensible. (2,3) Retained objects are considered a preventable occurrence, and careful counting and documentation can significantly reduce, if not eliminate, these incidents. (4,5) The "captain of the ship" doctrine is no longer assumed to be true, and members of the entire surgical team can be held liable in litigation for retained foreign bodies. (6-11) All team members should be committed to and involved in establishing meaningful policies and procedures related to surgical counts. (12,13)

RECOMMENDED PRACTICE I Sponges should be counted on all procedures in which the possibility exists that a sponge could be retained.

1. Sponge counts should be performed

* before the procedure to establish a baseline,

* before closure of a cavity within a cavity,

* before wound closure begins,

* at skin closure or end of procedure, and

* at the time of permanent relief of either the scrub person or the circulating nurse (although direct visualization of all items may not be possible).

2. Initial sponge counts should be performed and recorded, establishing a baseline for subsequent counts on all procedures in which the possibility exists that a sponge could be retained. Policies in the health care organization may identify situations in which this possibility does not exist and counts are not required. (14)

3. Accurately accounting for sponges throughout a surgical procedure should be a priority of the surgical team to minimize the risks of a retained sponge. (3,4,15,16) The Institute of Medicine has identified avoiding injuries from the care that is intended to help patients to be one of six aims to a better health care system. (17)

4. Established policies in the health care organization may define when additional counts must be performed or may be omitted (eg, cystoscopy, ophthalmology). (14) Closed claim studies conducted during the past 20 years have demonstrated that roughly two-thirds of reported cases of retained surgical items are attributed to sponges. (5,18-20) Although the majority of retained sponges are found in the abdomen and pelvis, there are reports in the literature discussing retained sponges in the vagina, thorax, spinal canal, face, brain, and extremities. (5,21-27)

5. Sponges should be separated, counted audibly, and concurrently viewed during the count procedure by two individuals, one of whom should be a registered nurse circulator. (3,17,28) Concurrent verification of counts by two individuals lessens the risk of inaccurate counts. Separating sponges during the baseline count helps to determine whether a sponge has been added to or deleted from a sterilized package. (2,4,17,29) Use of a pocketed bag or other system for separating used sponges may facilitate visualization for counting. Separating sponges after use minimizes errors caused by sponges sticking together.

6. When additional sponges are added to the field, they should be counted at that time and recorded as part of the count documentation to keep the count current and accurate. (4)