1, 2, 3, 4, 5. How hard is ensuring a correct count? Recently, at a national conference, I heard Dr. Robert Cima, chair of the surgical quality committee in our institution, discussing prevention of retained foreign objects (RFOs). In his presentation, he shared a dialogue he had with surgeon colleagues as he demonstrated the count process. He asked a surgeon colleague to begin counting sponges, then began interrupting him with questions and requests. We as perioperative nurses aren't surprised that the surgeon had difficulty completing a correct count. This exercise reinforced the necessity of focusing physician and nursing leadership resources on supporting an efficient and effective count process.
Our journey to no RFOs has been multidisciplinary and diverse in strategies. About 2.5 years ago, we implemented an automated sponge counter. Although this has been a focal point in our strategy to prevent RFOs, it's only a small part of a larger solution. The procedural guidelines were reviewed and revised to clarify the count process and incorporate the new technology of the automated sponge counter. Education was provided and required of all RNs, certified surgical technologists, and certified surgical assistants. Surgeons, residents, and all allied staff were required to read and sign a document which defines an RFO, discusses the failure to follow count policy as a contributing factor in 50% of RFOs, and includes a step-by-step outline of the sponge count process. Step-by-step information about the count process is displayed in every OR, on a red stop sign clearly visible to all staff entering the OR.
Management and leadership are committed to keeping prevention of RFOs in the spotlight. Several strategies have been implemented in order to maintain the gains we've made. To maintain continuous awareness, a poster is prominently displayed by the locker rooms showing the number of days since the last RFO. Staff are acutely aware when the number changes and intensely interested in what contributed to an incident.
Audits, competencies, and practice observations are tools used to evaluate practice. Sponge count audits are completed quarterly. Educators perform sponge count competencies with staff twice a year. Leadership (nurse managers, nursing education specialists, and the nurse administrator) performs learning observations. The purpose of these observations is to observe for compliance with policies and procedural guidelines, promote practice standardization, identify other potential practice issues, and review specific practice points, one of which is the sponge count process. Each OR is observed twice quarterly.
Prompt and definitive nursing management follow-up is initiated with those who aren't compliant with procedural guidelines. Staff is encouraged to speak up if members of the surgical team don't follow the sponge count process. If staff members feel their concerns are being dismissed, they're encouraged to call nursing management to intervene.
As a result of these efforts, we've had no retained sponges in 2.5 years. In an institution with about 1,000 staff in 120 ORs over three sites, the process has been extensive and persistent. The journey toward learning and improvement continues. Changing practice also includes changing culture. In my opinion, maintaining a standardized practice has been the greatest obstacle. A supportive, interdisciplinary leadership team and a relentless commitment to patient safety are key to achieving the best outcomes. A well-functioning team produces the best outcomes whether the focus is in the OR or in changing departmental practice.
Elizabeth M. Thompson, MSN, RN, CNOR
Editor-in-Chief Nursing Education Specialist Mayo Clinic, Rochester, Minn. [email protected]