Policy & Procedure Document

Section 11A: SEC 11 — Intra-Operative Safety & Conduct (11.1, 11.2, 11.3)

Independent Policies for Each Title

Operating Theatre Policy

POLICY 11.1 — OT Entry/Exit Control & Theatre Discipline

Department Operating Theatre (OT)
General Hospital
Version & Dates Version: 1.0
Effective: //20__
Review: //20__
Owner OT Nurse Manager + OT Charge Nurse Lead
Policy Code OT-IO-11.1
Related Policies: SEC 4 (Privacy/Dignity), SEC 6 (Verification/Time-Out governance), SEC 9 (IPC zoning & traffic discipline), SEC 7 (Transfers), SEC 3 (QPS reporting)

1.0 PURPOSE

1.1 Purpose Statement

1.1.1 To ensure that access to OT restricted areas and OR rooms is controlled, purposeful, and documented where required, to protect:

  • a) patient safety (reduced distraction, reduced workflow interruption, controlled risk during critical steps),
  • b) infection prevention (reduced traffic and door openings),
  • c) patient dignity and privacy (access control, restricted viewing), and
  • d) professional behavior and team performance.

1.1.2 To define theatre discipline standards that support safe surgery processes (verification, counts, specimen labeling, sterile field protection) by reducing nonessential movement, noise, and interruptions.

2.0 SCOPE

2.1 Included

  • 2.1.1 All OT suite areas: unrestricted, semi-restricted, restricted zones; all operating rooms; sterile core interfaces; scrub areas; OT corridors within OT suite boundaries.
  • 2.1.2 All personnel entering OT zones: OT staff, surgeons, anesthesia teams, CSSD runners, porters, housekeeping/EVS, engineering/biomed, students/observers, vendors/industry representatives.

2.2 Exclusions

  • 2.2.1 Hospital-wide security access policy (this policy defines OT operational controls within that framework).
  • 2.2.2 Clinical anesthesia management processes (covered by anesthesia policies), except for behavior and access controls while within OT areas.

3.0 DEFINITIONS

  • 3.1 Theatre Discipline: A set of behaviors and controls that maintain safe focus, privacy, cleanliness, and predictable workflow in the OR.
  • 3.2 Critical Steps: Steps where interruptions and traffic can increase risk, including: room setup, sterile field setup, patient entry/transfer to table, Sign-In, Time-Out, incision, implant opening/insertion, specimen handling/labeling, closing counts, Sign-Out, patient exit/transfer.
  • 3.3 Nonessential Personnel: Anyone not required for safe care of the current patient or for essential OT operations at that moment (including observers without active role, idle staff, nonassigned learners, unrelated vendors).

4.0 POLICY STATEMENT

  • 4.1 Access to restricted OT zones and OR rooms shall be controlled. Only authorized personnel with a defined role and correct attire may enter.
  • 4.2 OR doors shall remain closed. Door opening and room traffic shall be minimized, especially during critical steps.
  • 4.3 Only essential personnel may remain in the OR. The Charge Nurse and Circulating Nurse have authority to restrict access and request nonessential persons to leave.
  • 4.4 Theatre discipline standards apply to behavior, conversation, device use, interruptions, and movement. Nonclinical distractions are not acceptable in restricted zones.
  • 4.5 Any pattern of noncompliance that threatens safety, privacy, or infection prevention shall be documented and escalated through OT leadership and QPS processes.

5.0 ROLES AND RESPONSIBILITIES

5.1 OT Director / OT Chair

  • 5.1.1 Provides leadership backing for access control enforcement and supports escalation when conflicts occur.
  • 5.1.2 Ensures repeated breaches are addressed through OTMC/QPS actions.

5.2 OT Nurse Manager

  • 5.2.1 Ensures implementation, staff education, audit monitoring, and corrective actions.
  • 5.2.2 Ensures OT has functional access controls (badges/keys, signage, zone maps, visitor logs).

5.3 OT Charge Nurse (Shift Lead)

  • 5.3.1 Operational authority for room discipline, access control, and traffic restrictions.
  • 5.3.2 Ensures a runner role is assigned when needed to reduce door openings.
  • 5.3.3 Escalates repeated breaches to OT management.

5.4 Circulating Nurse (Per Case)

  • 5.4.1 Controls entry/exit during the case, protects sterile field from disruption, and pauses workflow if interruptions compromise safety.
  • 5.4.2 Ensures patient privacy is protected (draping, limiting room entry during positioning).
  • 5.4.3 Documents notable disruptions when they lead to risk, delay, or policy breach.

5.5 All OT Personnel, Surgeons, Anesthesia Teams, Vendors/Observers

  • 5.5.1 Comply with OT access discipline rules.
  • 5.5.2 Maintain professional conduct, quiet focus during critical steps, and avoid unnecessary movement.

6.0 PROCEDURE

6.1 Zone Entry Standards

6.1.1 All personnel must comply with OT zoning and attire requirements before entering semi-restricted or restricted zones.

6.1.2 Entry to restricted zones is permitted only for personnel who:

  • a) have a defined role for the case or essential OT operations,
  • b) have correct attire/PPE,
  • c) understand privacy and confidentiality rules,
  • d) comply with hand hygiene expectations.

6.2 OR Entry Authorization

6.2.1 The default rule is: only the case team and essential support are present.

6.2.2 Any nonteam entry requires one of the following:

  • a) direct operational requirement (equipment failure response, urgent supply delivery),
  • b) approved observation/teaching with patient permission when required and with supervisor identified,
  • c) approved vendor presence strictly for implant/equipment support with professional boundaries and minimal movement.

6.2.3 The Circulating Nurse or Charge Nurse may deny entry when:

  • a) the OR is in a critical step,
  • b) the room is crowded,
  • c) privacy risk exists (positioning/exposure),
  • d) sterility risk exists (open sterile supplies),
  • e) the person lacks proper attire or authorization.

6.3 Door Opening and Movement Discipline

6.3.1 Doors remain closed and fully latched. Propping open is prohibited.

6.3.2 Door opening is minimized by planning:

  • a) case cart and supplies prepared before patient entry,
  • b) implants and trays confirmed ready,
  • c) equipment checked and staged,
  • d) runner assigned outside OR for additional supplies.

6.3.3 If door entry is required:

  • a) knock → enter promptly → close immediately → no doorway conversation.

6.3.4 Staff movement during critical steps is restricted:

  • a) during Sign-In/Time-Out/Sign-Out, nonessential movement stops,
  • b) during sterile setup and implant insertion, movement is minimized.

6.4 “Critical Step Quiet Rule”

6.4.1 During critical steps, the OR follows a “quiet and focus” rule:

  • a) only task-related communication,
  • b) no side conversations, jokes, or unrelated discussion,
  • c) phones silenced except for clinical/urgent use.

6.4.2 If distraction occurs during Time-Out, the Time-Out is restarted from the beginning of the verification statement.

6.5 Personal Devices and Communication Tools

  • 6.5.1 Personal phone use in restricted zones is prohibited except for approved clinical communication.
  • 6.5.2 Photography/video is prohibited unless authorized under Policy 11.11.
  • 6.5.3 If device use occurs (approved), hand hygiene is performed before and after handling.

6.6 Visitors, Observers, Students, Vendors

6.6.1 Entry is permitted only when:

  • a) approved by Charge Nurse and relevant department rules,
  • b) patient permission is confirmed where applicable,
  • c) confidentiality agreement is in place,
  • d) the person is supervised and positioned away from sterile field,
  • e) the person does not increase traffic or distraction.

6.6.2 Limits:

  • a) number of observers minimized,
  • b) entry time minimized,
  • c) removal required immediately if safety/privacy is threatened.

6.7 Interruption Management

  • 6.7.1 The Circulating Nurse controls interruptions.
  • 6.7.2 Nonurgent interruptions are deferred until safe.
  • 6.7.3 Urgent interruptions are managed with minimal disruption: pause, address, resume verification if needed.

6.8 Escalation and Enforcement

  • 6.8.1 Immediate correction is required for all breaches (attire, unauthorized entry, door propping, disruptive behavior).
  • 6.8.2 Repeated breaches: documented and escalated to OT management.
  • 6.8.3 Serious breaches (privacy violation, unauthorized filming, aggressive behavior): immediate escalation and incident reporting.

7.0 DOCUMENTATION / RECORDS

  • 7.1 Visitor/observer/vendor log (where used).
  • 7.2 Incident reports for repeated breaches or any breach that creates risk/harm/near miss.
  • 7.3 Audit forms (door openings/traffic, discipline compliance).

8.0 AUDIT / KPIs

  • 8.1 Door openings per case (trend; high-risk procedures tracked separately).
  • 8.2 Number of interruptions during Sign-In/Time-Out/Sign-Out.
  • 8.3 Unauthorized entry events (count and corrective actions).
  • 8.4 Privacy breach events related to uncontrolled access.

9.0 APPENDICES

  • 9.1 Appendix A — OT Access Control Quick Rules (Poster)
  • 9.2 Appendix B — OR Critical Step Discipline Checklist (Audit Tool)
  • 9.3 Appendix C — Visitor/Observer/Vendor Entry Approval Form
Operating Theatre Policy

POLICY 11.2 — Safe Practices in OT / Environmental Hazards / Wrong-Site Prevention

Department Operating Theatre (OT)
General Hospital
Version & Dates Version: 1.0
Effective: //20__
Review: //20__
Owner OT Director/Chair + OT QPS Lead + OT Nurse Manager
Policy Code
Related Policies: SEC 6 (Verification, Site Marking, WHO process), SEC 9 (IPC), SEC 11.3–11.4 (Counts/RSI), SEC 7 (Transfers), SEC 4 (Privacy)

1.0 PURPOSE

1.1 Purpose Statement

1.1.1 To prevent intra-operative harm by controlling environmental hazards and ensuring safe behaviors that reduce:

  • a) staff injury (slips/trips, sharps injuries, electrical hazards),
  • b) patient injury (falls during transfer, burns, pressure/positioning harm, retained items),
  • c) catastrophic wrong-patient/wrong-procedure/wrong-site events, and
  • d) avoidable intra-operative disruptions that compromise safety and sterile practice.

1.1.2 To embed wrong-site prevention as a continuous discipline from patient entry to incision—not only as a single checklist moment.

2.0 SCOPE

  • 2.1 Applies to all intra-operative phases: room setup → patient entry → positioning → incision → procedure → closure → exit.
  • 2.2 Applies to all OR rooms and any OT-governed procedural room.

3.0 DEFINITIONS

  • 3.1 Environmental Hazard: Any condition in the OT that increases likelihood of harm (wet floor, clutter, unmanaged cables, unstable equipment positioning, poor lighting, poor waste segregation, open sharps, gas leak alarm).
  • 3.2 Wrong-Site Event (WSE): Wrong patient, wrong procedure, wrong side, wrong site, wrong level, wrong implant, wrong specimen labeling.
  • 3.3 Hazard Reporting: Immediate notification and documentation of unsafe conditions and near misses.

4.0 POLICY STATEMENT

  • 4.1 OT shall maintain a hazard-controlled environment before, during, and after surgery. Hazards are corrected immediately and not postponed “until after the case” unless correction would create greater risk.
  • 4.2 OT shall implement wrong-site prevention controls that include verification behavior before incision, continuous mismatch vigilance, and stop-the-line escalation when uncertainty exists.
  • 4.3 OT staff are empowered and obligated to speak up and request pause when they identify hazard or mismatch risk.
  • 4.4 OT shall document and report significant hazards, near misses, and events; trends are reviewed through OT QPS.

5.0 ROLES AND RESPONSIBILITIES

5.1 OT Charge Nurse

  • 5.1.1 Ensures room readiness and staffing that supports safe practice.
  • 5.1.2 Ensures hazards are corrected and escalated promptly.
  • 5.1.3 Ensures wrong-site prevention compliance culture is enforced.

5.2 Circulating Nurse

  • 5.2.1 Primary owner of intra-operative environment safety (floor, cables, equipment placement, spill response coordination, sharps container readiness).
  • 5.2.2 Ensures safe sequence of actions during critical steps (verification, positioning, prep/drape).

5.3 Scrub Nurse/Technologist

  • 5.3.1 Maintains sterile field integrity, safe sharps passing discipline, and controlled placement of sharps/instruments.
  • 5.3.2 Alerts immediately when sterile integrity is threatened by environmental disruption.

5.4 Surgeon/Proceduralist

  • 5.4.1 Participates fully in verification and supports pause when mismatch occurs.
  • 5.4.2 Confirms site, side, and procedure before incision and when changes occur.

5.5 Anesthesia Provider

  • 5.5.1 Participates in shared safety verification and supports environmental hazard control (cable management in anesthesia zone, oxygen/fire risk awareness).

5.6 All Staff

  • 5.6.1 Maintain safe behaviors and report hazards; do not normalize unsafe shortcuts.

6.0 PROCEDURES

6.1 Standard OT Safe Practices (Universal)

6.1.1 Clean floor / clear path rule:

  • a) floors are kept clear of packaging, cords, and wet areas,
  • b) waste is contained promptly,
  • c) movement routes are planned (to reduce tripping and contamination).

6.1.2 Cable/cord management:

  • a) cords are routed away from walking paths,
  • b) cords are secured where feasible,
  • c) equipment towers are positioned to prevent tipping,
  • d) power sockets are not overloaded.

6.1.3 Equipment placement discipline:

  • a) equipment must not block exits,
  • b) emergency access path is preserved,
  • c) suction and oxygen availability is confirmed per room readiness.

6.1.4 Sharps discipline:

  • a) sharps are never left loose on drapes or floor,
  • b) sharps are passed using an agreed method (including neutral zone where adopted),
  • c) used sharps go directly into sharps container,
  • d) sharps containers are available and not overfilled,
  • e) any sharps injury is treated as a reportable event with immediate exposure management.

6.1.5 Spill and wet floor discipline:

  • a) spills are controlled immediately using appropriate PPE and cleaning,
  • b) temporary signage is used when needed,
  • c) wet floors are dried quickly to prevent falls.

6.1.6 Fire risk behavior awareness (OT side):

  • a) alcohol-based skin prep must dry fully before draping and before electrosurgical activation,
  • b) towels/drapes are arranged to avoid pooling,
  • c) oxygen-rich zones are recognized as high-risk; open oxygen sources are managed according to facility fire policy,
  • d) ignition sources are handled carefully.

6.2 Environmental Hazard Identification and Immediate Correction

6.2.1 Hazards may be identified during room setup, procedure, or turnover.

6.2.2 When a hazard is identified, the responsible staff member does not ignore it. The required action is:

  • a) announce hazard (“wet floor”, “cord across walkway”, “sharps exposed”),
  • b) apply immediate control (remove obstacle, route cable, cover/contain spill),
  • c) if cannot be corrected immediately, escalate to Charge Nurse and apply temporary risk control (barrier, alternative route, additional staff supervision).

6.2.3 Examples of “must correct now” hazards:

  • a) wet floor near foot traffic,
  • b) electrical cord exposed to moisture,
  • c) sharps on field edge or on drapes without control,
  • d) overloaded extension plugs,
  • e) blocked emergency access route.

6.3 Wrong-Site Prevention (Continuous Controls)

6.3.1 OT wrong-site prevention is the sum of small disciplined confirmations—not a single event.

6.3.2 Before patient enters OR room:

  • a) OT verifies identity (two identifiers) at receiving point,
  • b) planned procedure and site/side consistency is checked against schedule and record,
  • c) any mismatch triggers hold and escalation (SEC 6).

6.3.3 Before positioning and draping:

  • a) site mark visibility is confirmed when required,
  • b) if drapes may cover the mark, confirm that mark verification occurred and is documented before draping proceeds.

6.3.4 Before incision (Time-Out interface):

  • a) the entire team states the same procedure/site/side,
  • b) if disagreement occurs, incision does not proceed.

6.3.5 Changes in plan during surgery:

6.3.5.1 If procedure changes (additional site, additional side, unplanned implant), the team pauses and repeats a focused verification:

  • a) what is changing,
  • b) whether consent and documentation support the change,
  • c) whether site marking/verification remains valid,
  • d) whether implants/equipment match the revised plan.

6.3.5.2 The change and verification are documented.

6.4 Standard Safety Behaviors During the Procedure

  • 6.4.1 No “silent assumptions”: If a staff member hears a different site/procedure than expected, they speak up immediately.
  • 6.4.2 Room discipline supports safety: door openings and traffic are minimized (linked to SEC 9).
  • 6.4.3 Instrument integrity awareness: detachable parts and device fragments are controlled and tracked; suspicion of missing fragments triggers escalation and documentation.

6.5 Event Reporting and Learning

6.5.1 Any of the following require reporting:

  • a) wrong-site near miss (caught discrepancy),
  • b) wrong implant near miss,
  • c) specimen labeling mismatch,
  • d) fall/near fall,
  • e) sharps injury/near miss,
  • f) fire hazard event (prep pooled, ignition risk identified),
  • g) repeated hazard pattern (same cords, same clutter location).

6.5.2 OT QPS reviews trends and implements system fixes (layout redesign, standard setup, supply staging redesign, training reinforcement).

7.0 DOCUMENTATION / RECORDS

  • 7.1 OR room readiness checklist (if used).
  • 7.2 Hazard correction log / incident reports (as applicable).
  • 7.3 Wrong-site discrepancy record (if occurs).
  • 7.4 Safety briefing/huddle notes (if facility uses them).

8.0 AUDIT / KPIs

  • 8.1 Environmental hazard audit compliance (cords, clutter, wet floor controls).
  • 8.2 Sharps injury and near miss rate.
  • 8.3 Wrong-site discrepancy/near miss rate.
  • 8.4 Equipment placement compliance (blocked access events).

9.0 APPENDICES

  • 9.1 Appendix A — OR Environmental Hazard Inspection Tool (Daily/Shift)
  • 9.2 Appendix B — Wrong-Site Prevention “Change of Plan” Verification Form (Short)
  • 9.3 Appendix C — Sharps Safety Quick Rules Card
Operating Theatre Policy

POLICY 11.3 — Surgical Counts (Sponges / Sharps / Instruments)

Department Operating Theatre (OT)
General Hospital
Version & Dates Version: 1.0
Effective: //20__
Review: //20__
Owner OT Nurse Manager + OT QPS Lead
Policy Code
Related Policies: Policy 11.4 (RSI prevention and discrepancy escalation), SEC 6 (Stop-the-Line), SEC 3 (Sentinel/RCA), SEC 9 (IPC)

1.0 PURPOSE

1.1 Purpose Statement

1.1.1 To prevent retention of sponges, sharps, instruments, and device components by establishing a standardized, repeatable, auditable count process that is:

  • a) performed consistently at defined times,
  • b) conducted audibly and visually by two people,
  • c) documented in real time,
  • d) supported by standardized tools (count sheets, sponge holders, sharps counters), and
  • e) linked to an immediate discrepancy response process.

1.1.2 To ensure count reliability remains strong even in challenging conditions: emergencies, multiple teams, staff relief, long cases, high case complexity, minimally invasive surgery, and high-volume turnover days.

2.0 SCOPE

  • 2.1 Applies to all surgical and invasive procedures performed in OT rooms where any countable item can enter the wound or body cavity or be at risk for retention.
  • 2.2 Applies to all sponges (all sizes/types), sharps (needles, blades, cautery tips if removable, wires), and instruments (including detachable components).
  • 2.3 Applies to both elective and emergency cases (with defined emergency exception handling).

3.0 DEFINITIONS

  • 3.1 Countable Items: Items that must be counted per OT count list, including:
    • a) sponges (radiopaque where required),
    • b) sharps (needles, blades, wires),
    • c) instruments (including detachable pieces),
    • d) miscellaneous items designated by OT (e.g., vessel loops, peanuts, dissectors if applicable to your local list).
  • 3.2 Count Discrepancy: Any mismatch between recorded count totals and items present/verified.
  • 3.3 Count Closure: Completion of required count at a defined stage with documented outcome (correct / incorrect / not performed with reason).
  • 3.4 Relief Count: Count performed when scrub and/or circulating staff change during the case.

4.0 POLICY STATEMENT

  • 4.1 Counts are mandatory. They are conducted as a two-person verification process between the scrub person and the circulating nurse, with active participation and attention.
  • 4.2 Counts are performed at standardized times (initial, closure phases, final, relief changes).
  • 4.3 Count documentation is done in real time. “Later documentation” is not acceptable.
  • 4.4 The surgeon/proceduralist is informed of count results, especially discrepancies, and supports a pause and search process when needed.
  • 4.5 The patient shall not leave the operating room with an unresolved discrepancy unless an approved escalation pathway is followed and documented (see Policy 11.4).
  • 4.6 Emergency situations may require modified timing; however, a structured approach and documentation remain mandatory.

5.0 ROLES AND RESPONSIBILITIES

5.1 Circulating Nurse

  • 5.1.1 Responsible for initiating counts at required times, documenting counts, maintaining count board/sheet integrity, and leading discrepancy response escalation.
  • 5.1.2 Ensures all additional items introduced are recorded promptly.
  • 5.1.3 Ensures counts are not rushed or skipped due to schedule pressure.

5.2 Scrub Nurse / Scrub Technologist

  • 5.2.1 Maintains organized field and countable item control (sponges in holders, sharps in counter box, instruments arranged).
  • 5.2.2 Participates in audible/visual count verification with the circulating nurse.
  • 5.2.3 Immediately announces when additional items are opened/added and ensures they are integrated into the count system.

5.3 Surgeon/Proceduralist

  • 5.3.1 Participates in acknowledgement of count status at closure phases.
  • 5.3.2 Responds immediately to discrepancy notifications by pausing closure/transfer actions as appropriate and participating in wound/cavity inspection.

5.4 OT Charge Nurse

  • 5.4.1 Supports staffing and resources when discrepancy occurs (additional staff, imaging coordination pathway through hospital process).
  • 5.4.2 Ensures repeated count issues are escalated to OT leadership/QPS for system fixes.

5.5 OT Nurse Manager / QPS Lead

  • 5.5.1 Maintains standard count tools, ensures training/competency, and monitors audit results and corrective actions.

6.0 STANDARD COUNT TOOLS AND SETUP REQUIREMENTS

6.1 Sponge Control Tools

  • 6.1.1 A standardized sponge holder/board is required. Loose sponges are not permitted.
  • 6.1.2 Only radiopaque sponges are used when sponges may enter cavities (per facility rule).
  • 6.1.3 Sponges are separated by type/size on the holder; mixing types in the same pocket is not permitted.

6.2 Sharps Control Tools

  • 6.2.1 A sharps counter/box is required.
  • 6.2.2 Used sharps are immediately placed into the sharps counter/box (not left on the field edge).
  • 6.2.3 Blades are managed with a defined neutral zone or controlled passing method.

6.3 Instrument Control Tools

  • 6.3.1 Instrument count sheets are used for each set.
  • 6.3.2 Sets with detachable parts have component lists and must be verified.
  • 6.3.3 Any device component removed/changed is treated as countable if retention risk exists (as defined by OT list).

6.4 Count Sheet Governance

  • 6.4.1 One official count record exists per case (paper or electronic).
  • 6.4.2 Corrections are made according to documentation rules (no erasing; single line correction with initials/date/time if paper).
  • 6.4.3 Count record remains part of the medical record package as per facility documentation policy.

7.0 PROCEDURE — COUNT TIMES AND METHOD

7.1 General Principles

  • 7.1.1 Counts are conducted in a controlled manner with minimal distraction.
  • 7.1.2 The circulating nurse and scrub person stand so both can see the items being counted.
  • 7.1.3 The count is audible: items are called out clearly and confirmed by both parties.
  • 7.1.4 The count is visual: items are physically seen and verified, not assumed.

7.2 Mandatory Count Schedule (Minimum)

7.2.1 Initial Count

  • 7.2.1.1 Performed before incision or before the procedure begins, once the sterile field is set.
  • 7.2.1.2 Includes: sponges + sharps + instruments + designated miscellaneous items.
  • 7.2.1.3 Document “initial count correct” with time and signatures/initials.

7.2.2 Cavity Closure Count (When Applicable)

  • 7.2.2.1 Performed before closure of any body cavity (e.g., abdomen, thorax) as defined by surgical type.
  • 7.2.2.2 If multiple cavities are entered, counts are repeated at each relevant closure stage.

7.2.3 Layer/Deep Closure Count (As Defined by Local Standard)

  • 7.2.3.1 Performed before closure of deep layers when items could remain hidden.

7.2.4 Skin Closure Count

  • 7.2.4.1 Performed before final skin closure begins.

7.2.5 Final Count

  • 7.2.5.1 Performed at the end of the procedure before the patient leaves the room.
  • 7.2.5.2 Confirms all countable items are reconciled and accounted for.

7.2.6 Relief / Staff Change Count

  • 7.2.6.1 If scrub or circulating staff change, a relief count is performed.
  • 7.2.6.2 The relief count includes sponges and sharps at minimum; instruments as defined by risk/phase and local rule.
  • 7.2.6.3 The outgoing and incoming staff sign the handover count record.

8.0 ITEMS OPENED/ADDED DURING THE CASE

8.1 Standard Addition Rule

  • 8.1.1 Every additional sponge, sharp, instrument, or countable item introduced after initial count must be announced and incorporated into the count record immediately.
  • 8.1.2 The circulating nurse documents the addition and the scrub person places the item into the standard control system (sponge board/sharps box/instrument list).
  • 8.1.3 “Temporary use” does not exempt counting—if it enters the field, it is controlled.

8.2 Special Handling

  • 8.2.1 Small items or detachable parts are at high risk for being lost. The scrub person announces them distinctly, and the circulating nurse records them as separate line items.

9.0 SPECIAL SITUATIONS

9.1 Emergency Life-Saving Conditions

9.1.1 If immediate incision is required to save life/limb and initial counts cannot be completed:

  • a) document “initial count not performed” with reason (emergency),
  • b) perform counts as soon as the patient is stabilized and workflow permits,
  • c) maintain best possible item control from the first moment (sponge board, sharps box).

9.1.2 Final count remains mandatory. If discrepancy occurs, follow discrepancy response pathway.

9.2 Multiple Teams / Multiple Fields

  • 9.2.1 One official count record is maintained.
  • 9.2.2 Transfer of items between fields is controlled and verbalized (“two sponges moved to second field”), documented by circulating nurse.

9.3 Minimally Invasive Surgery

  • 9.3.1 Trocar components and device tips that can detach must be tracked per local count list.
  • 9.3.2 Sponges used internally must be radiopaque and included in sponge counts.

9.4 Case Conversion (e.g., laparoscopic to open)

  • 9.4.1 When conversion occurs, the team pauses to confirm count status and adjust count plan for open field risk.
  • 9.4.2 Additional sponges/instruments introduced for open procedure are integrated and documented.

10.0 DISCREPANCY PREVENTION (BEFORE IT HAPPENS)

10.1 Prevention Behaviors

  • 10.1.1 Keep the field organized: no hidden sponges under instruments, no sharps under drapes.
  • 10.1.2 Separate used and unused sponges and maintain sponge board discipline.
  • 10.1.3 Keep sharps in the sharps counter box immediately after use.
  • 10.1.4 Use a defined “no handoff without count status” rule during staff relief.
  • 10.1.5 Do not rush counts due to time pressure; speed is never a justification to skip reliability steps.

11.0 DISCREPANCY DETECTION AND IMMEDIATE ACTION (INTERFACE TO POLICY 11.4)

  • 11.1 If any count is incorrect or uncertain, the circulating nurse immediately announces “count discrepancy” and informs the surgeon.
  • 11.2 The team pauses closure/exit activities and begins the standardized discrepancy response and search process defined in Policy 11.4 (RSI Prevention).
  • 11.3 All discrepancies are documented and reported as events/near misses even if resolved.

12.0 DOCUMENTATION / RECORDS

12.1 Count sheet includes:

  • a) initial count results,
  • b) additions,
  • c) closure counts,
  • d) relief counts,
  • e) final count,
  • f) discrepancy notes and actions (or link to discrepancy record),
  • g) signatures/initials of circulating and scrub personnel.
  • 12.2 Sign-Out includes explicit count status confirmation.
  • 12.3 Any “count not performed” entry must include reason and must be exceptional.

13.0 AUDIT / KPIs

  • 13.1 Count compliance: % cases with documented initial + closure + final counts.
  • 13.2 Discrepancy rate per 100 cases (sponges/sharps/instruments).
  • 13.3 Relief count compliance when staff change occurs.
  • 13.4 “Count status communicated to surgeon” compliance (audit observation).

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