4 Steps to Upgrade Counting Practices

When OR manager Hannah Shufeldt, DNP, MSHCM, RN, CNOR, observed an increase in incorrect counts at her facility and learned that a lap sponge was left in a patient, she was determined to find out why. She observed significant variance in counting practice among her teams.

Recognizing the need for a collaborative effort to address this issue, Shufeldt understood that change would require teamwork and patience to become ingrained habits.

“Asking team members to begin counting in a different way is sometimes a difficult ask. Especially for those who may have to change their practice more than another person,” she said.

So, she took a gradual approach with ample buy-in and engagement from the frontline and from leaders. And it worked.

Shufeldt and her perioperative teams across different surgical lines improved their counting practices to better align with the evidence provided in the AORN “Guideline for Prevention of Unintentionally Retained Surgical Items.”

During her presentation at AORN Expo 2024, titled, "Counting: Policy Transformation and Best Practice Implementation," Shufeldt provided insights on applying this information in the operating room and offered guidance on introducing and implementing a new counting policy grounded in best practices. The session is now available through Virtual Pass.

Here are the four key steps Shufeldt and her team implemented to enhance their counting practices:

Step #1: Introduce the idea for counting changes to your team

I met with my supervisor to share my concerns and ask how I could be a part of making improvements. After receiving approval to spearhead the initiative, I enlisted the support of leadership and members of the patient safety team to gather diverse perspectives.

Next, we used a staff meeting to share our reasoning for change specific to incorrect counts and the retained lap sponge. I provided education on the AORN guideline for preventing RSIs and emphasized best practice standards.

I concluded by inviting staff to return to the next monthly staff meeting with their ideas and suggestions on how they envisioned our counting processes evolving.

Step #2: Listen to team ideas for counting improvements

At our next staff meeting, I had a group of key staff come back with suggestions for change to reduce variance and standardize counting. These ideas shaped our approach for change. And the staff who proposed these changes became champions for helping me develop, promote, and implement our new practices.

Step #3: Review your current policy against proposed counting changes

Make sure you really understand your facility’s policy, because sometimes the problem isn’t with the policy itself but with staff needing more clarity on how to follow it correctly.

We found areas in our policy and counting practices that needed improvement, and then we reviewed these changes against the evidence. The goal was to make sure the changes made sense and were backed up by good information.

Step #4: Introduce counting changes gradually

Building on our policy update, we implemented three major changes. Each change was introduced individually over a 6-month period to allow staff to become comfortable with one thing at a time. 

• First, we revised how to count soft goods.
  I developed a new soft goods count sheet for staff, which includes both the previous soft items and additional ones that were previously overlooked.
• Next, we started counting instruments by tray.
  We changed practice to require a full instrument count before laparoscopic and thoracoscopic surgery. I created instrument count sheets in our hospital’s instrument tracking system for every tray. These sheets are attached to their matching tray and instruments are counted in like groups by the tray they are packaged in.
• Last, we added white boards to every OR with most commonly used and retained items on it.
  This requires staff to document these items on the soft good count sheet and the white board so the team at the field can visualize these items being added.