ICID > Clinical Management > General Surgery > Swab Instruments and Needle Count  
 

Swab Instruments and Needle Count 

  •  
  • 1. Indications
  • 2. Clinical Management
  • 3. Patient Information
  • 4. Audit
  • 5. Evidence Base
  • 6. Appendices
  • 1. Indications

    Background

    Although UK law does not dictate what system or method of swab, instrument and needle count should be performed, best practice and evidence based practice advocates the need to apply a logical process to enable practitioner’s to identify errors in the process. The safeguard of the patient is paramount and processes must be in place to ensure that no foreign body is retained by accident in any patient.

    Aim/purpose

    This policy has been developed to ensure that:

    1. Operative Counts, which includes, swabs, needles, instruments and extra’s are accurate and everything is accounted for at all times during a surgical procedure.

    2. It applies to all patients undergoing any type of intervention/surgical procedure within Salisbury District Hospital.

    To identify good clinical practice within theatres and to ensure the health and safety of patients through their journey within the operating theatre.


    2. Clinical Management

    Responsibilty for the count:

    1. Each count must be performed by two members of staff, one being a registered practitioner i.e. Nurse, Operating Department Practitioner or Midwife. These two members must be able to recognise and identify the instruments they are counting.

    2. The same two people should perform all the counts that are done during that procedure.

    3. If it becomes necessary to replace the scrub practitioner then a full count should be done prior to the scrub practitioner standing down and the names recorded in the Care Pathway.

    4. If a Consultant or Senior Surgeon leaves the theatre during or nearing the end of a procedure, then again a full count should be done and the surgeon continuing the case is made aware of the count.

    5. All items which are to remain in the patient i.e. catheter, drain or packing gauze should also be recorded on the Care Pathway.

    6. All swabs should be x-ray detectable.

    7. All items used must remain in the operating area until the procedure has been completed and all swabs should be discarded into the same clinical waste bag at the end of the procedure.

     Checking Procedure: (Prior to surgery commencing)

    1. A swab, needle and instrument count must be performed prior to any surgical procedure and the tray sheets must be completed. Extra’s should also be recorded – see Appendix A for list of extra’s.

    2. The count should be recorded on the standard white board for all procedures. A further board is available to record any extra instruments used during the procedure. The swab count should be done in multiples of 5’s i.e. 5 + 5 + 5, as subsequent packs are opened.

    3. One of the practitioners must count aloud the items, the x-ray detectable (radiopaque) strip must be shown and the integrity checked, this includes the tags on the larger swabs.

    4. Swabs and packs should be counted in bundle of 5’s and the red string tags that accompany them must be kept by the scrub practitioner as an additional check on the number of swabs used.

    5. Throat swabs should also be recorded on the white board.

     During and the end of the procedure:

    1. Any additional items used should be recorded on the boards as they are given to the scrub practitioner.

    2. If a large gauze roll is used a nylon stitch must be used and an artery clip attached, this must also be recorded on the board.

    3. If a ‘FISH’ is used this must have a large artery clip i.e. Roberts clip attached to the tail end and this clip must remain outside of the patient and must be recorded on the white board.

    4. Used swabs should be discarded into a ‘runner’ and should be counted out in bundles of 5 off the sterile field. Standard precautions should be maintained.

    5. The scrub practitioner should be aware of where all their instruments and swabs are at all times during the procedure. Any swabs placed inside a cavity should be recorded on the white board.

    6. A count should take place prior to the cavity being closed; this count should include everything that has been recorded on the white boards so far, ensuring all screws on the instruments and small items are in place. At this point the operating surgeon should be informed that all is present and correct and agreement reached that it is safe to begin to close, the surgeon verbally must acknowledge this.

    7. The count should be uninterrupted and verbally communicated. Some instruments may be removed into the sluice either with a specimen or a placenta, any instruments not visible to the scrub practitioner should be recorded on the extra’s board.

    8. The next count should be at the next level of closure.

    9. The final count should be done when the skin closure begins, this again must be a count of everything recorded and all instruments and extra’s, again the surgeon should be informed and should acknowledge this before the final closure of the skin layer.

    10. All counts should be undertaken before the patient leaves theatre. All swabs, needles and trays should have been checked as in above 6, 7 and 8.

    11. The counts should be ticked and signed for in the Care Pathway.

    12. Instrument trays - instruments to be placed back on to the tray in order of the tray sheet. Instruments to be placed back on their ppins. Tray sheets to be correctly and accurately completed. 

     Potential Complications – Count discrepancy

    1. If a discrepancy in the count is identified, the surgeon must be informed immediately and a search undertaken

    2. If a swab discrepancy is identified a recount of all swabs should take place and all plastic and clinical waste bags should be checked.

    3. If the item cannot be located a plain x-ray should be performed.

    4. Missing micro – needles that cannot be picked up on x-ray should be recorded in the patients notes and the Care Pathway.

    5. All missing items should be documented in the patient notes and an adverse incident form should be completed.

    6. The surgeon must help in the search and if they decline to acknowledge there is a problem seek senior help immediately.

    7. Any swabs that are intentionally left inside the patient must be recorded on the Care Pathway and the patients medical notes.

    8. An A.E.R. form should be completed and the surgeon should complete sheet 2 of that form before leaving the area.


    3. Patient Information


    4. Audit

    4.1 Standard

    Aspect of Care % Exceptions Definition
    That all aspects of the Swab, Instrument and Needle Count Policy in the Theatre Care Pathway documentation is complete 100 None Documentation in the pathway

    4.2 Audit tool

    At the end of every month for 6 months 30 sets of surgical notes will be sampled to   record the outcome of the documentation recorded in the theatre care pathway.

    5. Evidence Base

    5.1 References

     

    AfPP 2007 Standards and Recommendations for Safe Perioperative Practice

    AORN 2006 Recommended Practices for Sponge, Sharp and Instrument Counts.


    6. Appendices

    Appendix 1 Countable items  appendix


    Document Owner Sharon Berry 
    Department
    Review Date
    Document Status
    Revision Number
    1.1