Before you can fully appreciate our obsession over the items found up at the surgical field, you have to know why. Despite modern technology, and as odd as it may seem, leaving behind a sponge or instrument still manages to consistently make it near the top of the list of “Major Mistakes in Medicine” every year. To avoid this, we are number-fixated. There is not a nurse, scrub, resident, or attending who wants to leave something behind in a patient and we will generally do everything possible to keep it from happening. Thus, the count.
Every needle, sponge, instrument, and anything else that could potentially fit into the patient’s operative wound must be counted. Not just once, but multiple times. This means before incision and at the end of the case at a minimum. Every number of every item counted at the beginning of the case, plus or minus any items that may have been opened/taken away during the case, must match the numbers at the end of the case. There are no exceptions. If you need something or have a question for your scrub technician or circulator and you hear numbers coming out of their mouths and see papers in hand, do not interrupt. The count requires our full attention.
All instruments that are present prior to a case should be present at the end. As you can see from the list in Figure 11.2, tracking each item (and this is only one pan of instruments) is no small task. Pans come up from the sterile processing department with instruments on a “string” consisting of two “rods” that are strung through the handles of each instrument (Figure 11.3). We hope that they are strung in the same order that they are listed on the sheet, as that makes it easier for the scrub technician to quickly move through and announce the amount of each type of instrument, while the circulator follows along in order, with paper and pen in hand. The amount of each type of instrument is noted. The circulator will keep these papers throughout the case and note on the sheet if anything is added or removed.
Instrument list of items in a pan. (Photo used with permission from Ruth Braga, University of Utah.)
Instruments for a case on a string. (Photo used with permission from Ruth Braga, University of Utah.)
As the surgeon approaches the closing process, the circulator will pick up that same piece of paper and the scrub technician will organize the instruments once again to prepare for the count. I am always in awe of the scrub technicians at this point. Items have been moved around the field throughout the case and are still in use for the closing process, all while they are counting.
“We’re Missing An Instrument”
If the scrub technician states during the closing count that there are four Kelly clamps on the surgical field but the circulator noted there were five at the beginning of the case, the OR team is informed that this item is missing and each person will look around them. If you are at the field, carefully look around yourself and lift your feet to see if something fell on the floor. Sometimes an instrument has fallen on the floor without being noticed. If you are scrubbed in and up at the field when an instrument or something else falls, tell the circulator or scrub technician right away that it fell. You will save everyone the search time. If you are not scrubbed in and notice that something has fallen, speak up so it can be set aside and accounted for. Whatever you do, don’t throw it out—surgical instruments are very expensive.
Many circulators like to make a special place to put instruments or other items that fell or are no longer in use but still need to be accounted for. Whatever method you use, make sure others know about it. I have crawled around on my hands and knees, dug through trash, and called other nurses or scrub technicians at home to find out where they put something. I’ve even gone so far as to poke surgeons in the legs to get them to move their feet so I could look for something.
If the missing item is not on the floor, hidden under a drape, or anywhere else to be found, the patient will need an x-ray to make sure the unaccounted-for instrument was not left inside the patient. Institutional policies may vary but in most places if a patient requires an x-ray because an item is missing, they must stay under anesthesia until the x-ray has been taken and read by a radiologist to confirm that the item was not left behind. Incident reports or other reporting may be required, as this can be a serious patient safety issue.