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

    1.1 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.

    1.2 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.

    To reduce the incident of a “never event” and promote engagement in the World Health Organisation (WHO) checklist process.

    1.3 Scope

    The Royal College of Surgeons in their Good Surgical Practice (2008) states that “surgeons work in partnership with others in the health care team – which includes other professional, technicians, support staff and management – in order to offer safe and effective care to patients. They must work to develop effective relationships, respecting the professionalism of all colleagues. Knowledge and understanding of, and respect for, the roles and views of others are essential to achieving good patient outcomes.”

    The NMC Code of Conduct (2007) states that “as a professional, you are personally accountable for actions and omissions in your practices and must always be able to justify your decisions.”

    The Health Professions Council (2008) states that as a professional “you must act within the limits of your knowledge, skills and experience and. If necessary, refer the matter to another practitioner and that you must communicate properly and effectively with service users and other practitioners.”

    2. Clinical Management

    Responsibility 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 scrub practitioner must take lead for carrying out the surgical counts. This must be done in a systematic manner involving the circulating practitioner. Both members must count audibly and in unison with each other to acknowledge the items.

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

    4. 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.

    5. 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.

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

    7. All swabs should be x-ray detectable.

    8. 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 dry-wipe white board which is pre-printed and displays all significant items used for all procedures. The swab count should be done in multiples of 5’s i.e. 5 + 5 + 5, as subsequent packs are opened.

    3. The scrub practitioners must count and identify all items audibly, 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 packs should also be recorded on the white board.

    6. If an instrument tray is incorrect when doing the initial count, it should be either removed and a new one opened or continue to be used if the scrub practitioner is satisfied that the instrumentation required for the procedure is present. However, the missing instrument must be documented on the instrument check list and sterile services department informed.

    7. If there is a package containing less or more than the number that should be there, they are to be collected, bagged, labelled and passed off to the circulating practitioner. These items must then be removed from the theatre to reduce the potential for error in subsequent counts.

    During and the end of the procedure:

    1. Any additional items used should be recorded on the board 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, sharps and swabs are at all times during the procedure. It is recommended that neatness should be encouraged so to ensure that only essential items are used for the procedure and reduce the risk of missing items.

    6. Any swabs placed inside a cavity should be recorded on the white board. An abdominal quadrant map attached on the white board is used to help indentify area where the swab is placed inside the cavity by marking an “X”.

    7. A count should take place prior to the closure of a cavity or a cavity within the cavity; this count should include everything that has been recorded on the white board 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 must acknowledge this verbally.

    8. 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.

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

    10. 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.

    11. 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.

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

    13. Instrument trays - instruments to be placed back on to the tray in order of the tray sheet. Instruments to be placed back on their pins. 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, and an immediate peri-operative environment search carried out.

    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. A DATIX report should be filled in and inform the Surgeon, Theatre Coordinator and The Clinical Lead.

    3. Patient Information

    4. Audit

    4.1 Standard

    Aspect of Care




    That all aspects of the Swab, Instrument and Needle Count Policy in the Theatre Care Pathway documentation is complete



    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

    1. AfPP 2007 Standards and Recommendations for Safe Perioperative Practice

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

    3. Rothrock J (2002) p36-37 Rothrock J in: Alexander’s care of the patient in surgery. London, Mosby.

    6. Appendices

    Appendix 1 Countable items  Appendix 1

    Document Owner Catherine Steirn 
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