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2. Surgical Counting
Counting for all accountable items throughout the
operative procedure(s) includes :-
1) Before the procedure to establish a baseline
(#Initial Count)
2) Prior to closure of a cavity within a cavity
(#Additional Count)
3) Before wound closure begins (#First Count)
4) At skin closure or at the end of the operative
procedure(s) (# Final Count)
5) At the relief of the scrub person (# Relief Count)

3. Purpose of Surgical
Counting
 To ensure all items used during surgical
procedure are removed
 Reduce the risk of injury (ACORN,
2006)
 Gold standard to manage this risk
(Gibbs, 2003)
 Responsibility of peri-operative RN in
charge of the case

4. Major items required to be
counted
Absorbent Items Sharps
Vascular Items
Disposable Retraction
Instruments
Major countable
Items

6. Sentinel Event
Unexpected
Occurrence
• Death
• Physical
Injury
• Psychological
Injury
Loss of
Limb
• Loss of
function
• Risk thereof
• Immediate
investigation
required
Focus on
RSI
• Retained
surgical
instrument

8. HOSPITAL AUTHORITY (HS)
 Statutory Body under Hospital Authority
Ordinance
 Manage Hong Kong’s Public Hospitals
 Accountable to Hong Kong Special
administrative
Region Government
 Contribute to fulfillment of Hong Kong SAR
Government’s policy

10. HA Sentinel Events (SEs)
4 5 4 6 7 6
20
18
16
14
12
10
8
6
4
2
0
2007/08 2008/09 2009/10 2010/11 2011/12 2012/13
80 cases
RSIs in Other
Departments
RSIs in
Operating
Theatre
(32 cases) 40%

11. Siteof RSIs
37%
Abdomen
Extreme
Tonsillar bed
Eye
Thoracic
Oesophagus
Other
Quantity
(Counting)
11
Type of RSIs
63%
Tiny dislodged
fragment or broken
part
Raytec gauze &
Abdominal pad
Malleable
retractors
Contributing factor of RSIs
68%
Quality
(Integrity)
http://www.ha.org.hk/riskalert

12. RSIs in
Open Surgery
40%
Open Abdominal
Surgery
Open Other Surgery
RSIs in
Minimally Invasive Surgery
67%
Laparoscopic
Surgery
Endoscopic Surgery
67%
Raytec gauze or
abdominal pad
Malleable retractors
100%
Tiny disloged
fragment or broken
part

13. Complications due to RSI
 Perforation of bowel
 Sepsis
 Loss of Limb or function
 Death

16. A segment of plastic insulated sheath of a
laparoscopic instrument was retained inside
2008
Gyn. Lap. surgery
Plastic insulated sheath of a lap. forceps
Abdomen
HA Risk Alert, Issue 4 (2008)
patient
16

17. Contributing Factors
Difficult specimen retrieval
• Peeling off a piece of instrument
coating
Improper integrity of instruments
• No proper checking of instruments
before the end of operation

18. Recommendations
Non Insulated metal
• Instrument can be used with non
insulated metal outer tube for
specimen retrieval
Ensure integrity of instrument
• Instruments should be checked for
their integrity before the end of
operation

20. An oval shaped metallic clamp button
from stapler was retained in patient’s
abdomen
20
2008
Lap. resection of rectum
Metallic clamp button from the stapler
Abdomen
HA Risk Alert, Issue 7 (2008)

22. Grasping forceps was left in abdomen of
patient
22
2009
Metal plate inside the lumen of the forceps
Abdomen

24. A metallic covering defect at the end of the
70 degree telescope was found
24
A fragment of the end of telescope

25. Details
Contributing Factors:
 Difficulty in detecting
defect of delicate
instruments.
 Low awareness of
staff on checking
instruments integrity.
Recommendations:
 Use LED H and
Magnifier for
facilitating checking
and inspection of
instrument integrity
 To document details
of scopes sued in
surgical operations.

26. Causative factors to RSIs
26
Cause-effect diagram
RSIs
Lap. surgery
Organization Method/Process Instrument
Work Environment Staff Patient Communication
Scrub person
-Distraction by
surgeon
-lack of awareness
on integrity of
Instruments
-Plenty of
instruments for
counting
-Spare parts/
screws
easily dislodged
-Long
operation
time
-Obesity
Scrub person- surgeon:
No confirmation of
correct counting
before closure
Scrub person-circulating
nurse:
No consistent sequence
in counting
Low compliance
on SAG standards
of checking
the instruments’
integrity when
closure of wound
No structured
policies to reduce
the risk of RSI
-Hasty environment
- Inadequate time for
checking the integrity
of instruments when
closure of cavity &
wound

28.  The swab and instrument count is essential
and plays key role in enhancing surgical
patient’s safety (Woodhead and Fudge,
2010).
 Greenberg (2008) concluded that one in
eight surgical cases involves an intra-operative
discrepancy
 Instruments can be retained during
laparoscopic procedures, therefore, initial
instrument counts should be performed
(AfPP 2007, AORN 2010, ACORN 2006,
SAG 2010, AST 2006)

30. First P:
Practical utilization of laparoscopic instruments
30
Revised
G104-01
General & Team
B
Lap. Surgery
Revised
G104-02
Team D & U
Lap.
Surgery
Created
G104-03
Team A
Lap.
Surgery
↓ 3% ↓17% ↓47%

31. Second P:
Practical utilization of laparoscopic
instruments
31
Supplementary laparoscopic instrument
Screws
Screw x 2
Screw x 1
Screw x 2
Metal Ball (左
右) x 2
鍋釘(左右) x
2
螺絲帽x
1

32. Third P:
Partition of Used & Unused
laparoscopic instruments
32
Separating
Additional instrument tray

33. Fourth P:
“Partial Count” in Laparoscopic surgery
Initial counts 1st
Closing count
2nd
Closing
count
3rd
Closing
count
Before sending
to CSSD
Relief count
AfPP (2007) UK / Nurses
AORN (2010) USA / Nurses
ACORN (2006) Australia/ Nurses
ACS (2005) USA / Surgeons
SAG (2010) HK / Nurses
AST (2006) USA / Technologists
Before the
procedure
Before closure
of a cavity
within a cavity
Before
wound
closure
begins
At skin
closure or
end of
procedure
At the time of
permanent relief of
either the scrub
person or circulator
Laparoscopic surgery After all trocars removed
(Closure of peritoneum, muscle layer, and fascia
en masse in laparoscopic surgery)
Absorbent items Yes Yes Yes
Sharps & Other miscellaneous
items
Yes Yes Yes
Basic
instruments
Yes No Yes Yes
Laparoscopic
instruments
ALL
Laparoscopic
instrument
Used
Laparoscopic instrument
ALL Laparoscopic
instrument
ALL
Laparoscopic
instrument
Counted &
a visual
inspection for
completeness
A visual inspection for completeness Counted &
a visual
inspection for
completeness
Counted & a visual
inspection for
completeness
33

35.  Prescriptive nature of procedure
 Lack of clarity what constitutes an
‘accountable’ item
 Failure to consider current technologies
and use of plastics and other X-ray
detectable items (Hamlin, 2005)

37. Pilot study
Phase 1
15 Elective
Laparoscopic
Colorectal Surgery
5
patients excluded
2 patient
convented to open
surgery
3 patients' scrub
persons were not
trained
10
patients included
Phase 2
5 Elective
Laparoscopic
Urological Surgery
4
patients included
1
patients excluded
1 patient
convented to open
surgery
37

38. 38
Full count
231 236
326
200
180
240
330
350
250
360
400
350
300
250
200
150
100
50
0
1 2 3 4 5 6 7 8 9 10
Time (Seconds)
Full count: 4’30”

39. 39
Partial count
200
180
195
109
171
103
122
103
187
180
65
234
183
90
250
200
150
100
50
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Time (Seconds)
Partial count: 2’32”

40. 40
Full count – Partial count
4’30”
2’32”
300
250
200
150
100
50
0
Full Count (N=10) Partial Count (N=14)
Time (Seconds)
Efficiency: ↑44%

41. 41
Number of Used Lap. instruments
2’44”
1’18”
180
160
140
120
100
80
60
40
20
0
More than 12 (n=12) Fewer than or equal to 12 (n=2)
Time (Seconds)
Efficiency: ↑52%

42. 42
Experience of “Partial Count”
2’52”
1’59”
200
180
160
140
120
100
80
60
40
20
0
Inexperienced (n=9) Experienced (n=4)
Time (seconds)
Efficiency: ↑30%

43. 43
Instruments -- Experience
5’06”
3’38”
3’12”
1’30”
2’17”
1’5”
350
300
250
200
150
100
50
0
More than 12 Fewer than or equal to 12
Full Count
(Inexperience, n=10)
Partial Count
(Inexperience, n=9)
Partial Count
(Experience, n=4)
Efficiency:↑55% Efficiency:↑70%

44. 44
Evaluation
Effectiveness Efficiency
Communication Safety

45. Effectiveness
45
120%
100%
80%
60%
40%
20%
0%
Surgeons
Nurses
Q1.
This modified checking
procedure can enhance
counting strategy
development.
Rating: 95%
5% Strongly Agree
90% Agree
5% Disagree
80%
70%
60%
50%
40%
30%
20%
10%
0%
RR: 95% (N=21, Doctors, n=7, Nurses,
Surgeons
Nurses
Q2.
This checking method is
appropriate to apply in our
OT situation.
Rating: 81%
10% Strongly Agree
71% Agree
19% Disagree
120%
100%
80%
60%
40%
20%
0%
Surgeons
Nurses
n=14)
Q3.
The counting procedures are
in precise and effective way.
Rating: 100%
5% Strongly Agree
95% Agree

46. 46
Efficiency
80%
70%
60%
50%
40%
30%
20%
10%
0%
Surgeons
Nurses
Q4.
Nurse and surgeons are familiar
with the counting sequence:
Head-Neck-Body-Tail-
(complete).
Rating: 86%
14% Strongly Agree
72% Agree
14% Disagree
80%
70%
60%
50%
40%
30%
20%
10%
0%
Efficiency: ↑55% ＞12, ↑70% ≦ 12
Surgeons
Nurses
Q5.
You believe that the
turnaround OT time will not
be delayed.
Rating: 72%
10% Strongly Agree
62% Agree
28% Disagree
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Surgeons
Nurses
Q6.
This is an efficient and safe
counting procedure.
Rating: 100%
14% Strongly Agree
86% Agree

47. 47
Communication
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Surgeons
Nurses
Q7.
You have got the basic
information introduction of
Retained Surgical Items
(RSIs).
Rating: 95%
19% Strongly Agree
76% Agree
5% Disagree
60%
50%
40%
30%
20%
10%
0%
Surgeons
Nurses
Q8.
(Nurse) - You have got
surgeons' collaboration and
understanding.
Rating: 64%
7% Nurse Strongly Agree
57% Nurse Agree
29% Disagree
7% Strongly Disagree
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Surgeons
Nurses
Q9.
Surgeon shown compliance
on "Pause for Counting"
Rating: 86%
19% Strongly Agree
67% Agree
14% Disagree

48. 48
Reducing of RSIs
Q10.
It would reduce the Risk of RSIs at a lowest rate.
Rating: 95%
19% Strongly Agree
76% Agree
5% Disagree
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Strongly Agree Agree Disagree Strongly
Disagree
Surgeons
Nurses

49. 49
Implication

50. Future Development
Standard
Operating
Procedure
(SOP)
Guideline for all
laparoscopic
procedures
Guidelines for
Specialty Nursing
Services
(Perioperative
Care)
50