Pediatric instrument counts

AORN Journal,  Nov, 2007  by Bonnie Denholm

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QUESTION: We are evaluating our count policy for pediatric patients undergoing the herniorrhaphy procedure and whether the policy needs to be consistent between the inpatient OR and our hospital-based ambulatory surgery center (ASC). Personnel from the inpatient OR believe that it is important to continue performing final instrument counts. Personnel from the ASC are advocating for a policy that includes initial instrument counts but does not mandate a final instrument count if it is not deemed necessary. Does AORN have a statement specific to pediatric instrument counts?

ANSWER: AORN's "Recommended practices for sponge, sharp, and instrument counts" states "Instruments should be counted for all procedures in which the likelihood exists that an instrument could be retained." (1/(p49)) It further states that

   Organizations should define when instrument
   counts should be performed for pediatric
   patients. Instrument counts may be deferred
   when there is no perceived risk of retained
   instruments. (1(p497))

Policies and procedures should be the same between inpatient and outpatient settings and any other areas in which instrument counts may be necessary. If leaders in a health care organization believe it is best to continue performing final instrument counts on all hernia procedures, perioperative nurses might consider ways to increase efficiency in counting instruments. One solution to promote consistency between the two settings may be to reduce the number of instruments in trays so that only necessary instruments are opened on the sterile field.

Standardized count procedures and established routine counting practices are important strategies for reducing the risk for errors. When studying human errors, researchers have reported that deviation from routine practice is commonly found when errors occur. (2) The policy should establish a routine process for counting by stating that initial instrument counts are to be performed in all cases and the perioperative team should initiate another count just before closing the wound for every procedure. If the incision is small, the perioperative team could initiate an assessment at the time of closing to achieve consensus that there is not a risk of a retained instrument before omitting the final instrument count. Results of a consensus decision not to perform a final instrument count should be documented.

There are two important reasons to continue to do initial instrument counts:

* to establish a baseline for subsequent counts in the event the planned incision needs to be extended to allow for a more extensive procedure and

* to establish a routine for conducting counts.

For subsequent counts, the primary reason is to reduce the risk of patient injury as a result of a retained foreign body. The second instrument count, however, also may help to reduce loss of inventory, decrease the incidence of worker injury if a sharp instrument is misplaced in the drapes or trash, and reduce the risk of a misplaced instrument interfering with a subsequent count on a following procedure that takes place in the same OR.

When a health care organization reviews and updates policies and procedures for counts, considerations should include, but not be limited to:

* items to be counted;

* directions for performing counts (eg, sequence, item grouping);

* procedures in which baseline and/or subsequent counts may be exempt;

* alternative or additional safety measures for special circumstances;

* nursing actions and procedures for count discrepancy reconciliation; and

* competency validation. (1)

Counts are performed to lessen the potential for injury to the patient as a result of a retained foreign body and to account for all items. To promote optimal perioperative patient outcomes, health care organizations should develop counting policies and procedures that are consistent between all perioperative areas and support the perioperative practitioner in achieving complete and accurate count reconciliations.

REFERENCES

(1.) Recommended practices for sponge, sharp, and instrument counts. In: Standards, Recommended Practices, and Guidelines. Denver, CO: AORN, Inc; 2007:493-502.

(2.) Reason J. Safety in the operating theatre--part 2: human error and organisational failure.. Qual Safe Health. 2005;14(1):56-60.

BONNIE DENHOLM

RN, MS, CNOR

PERIOPERATIVE NURSING SPECIALIST

AORN CENTER FOR NURSING PRACTICE

COPYRIGHT 2007 Association of Operating Room Nurses, Inc.
COPYRIGHT 2008 Gale, Cengage Learning