Incorrect instrument counts

[tdstoughton]

I have just started working at a Medical center, after recently moving to the area. I am still on orientation, and was orienting on a Total Abdominal Hysterectomy. It was change of shift and the RN precepting me had to leave. Another nurse came in to watch over me until the end of the shift. The original preceptor had done the original instrument count at the beginning of the case. After a while, the scrub person had to leave as well and her relief came in to relieve her and they initiated a change of shift count. The 2nd preceptor, had me to do the sponge and instrument count with them. Everything was fine until we got to the laheys, and the long allis clamps and there was 1 extra of each of them on the case, that never got counted in the first place, because they weren't strung together properly when packaged in the tray. (I have heard that this has been a problem for some time, and that all the scrub techs are complaining because the count sheets either don't match whats in the tray, or the stringers are not strung together in groups properly, making counting everything a nightmare.) I made the scrub tech mad because I informed the surgeon that we were over on our instrument count by 2 clamps, and asked him what he would like to do, he was mad, but did a thorough inspection of the abdominal cavity and pronounced that he was fine with the count the way it was. I still had questions, at the end of the case, so I informed the charge nurse, who told me that they never worry about it if they are over on an instrument, so long as the surgeon is ok with it. This still bothers me, because everyone seemed so non-chalant about it. My question is do I make the Director of Surgery aware of this matter, and do I fill out a Risk identification report about it. The initial scrub tech was very angry at me, however, I feel that they have put my RN license at jeopardy, if I do nothing about the matter. This scrub tech in question, hates to do instrument counts and often goes over my head to the director if I call her out on something. I don't want to make enemies at my new place of employment, but I want to be a good patient advocate, because I would hope that someone would care enough to do the same for me if I was the patient.

[TakeTwoAspirin, MSN, RN, APRN]

You should complete an incident report form, and risk identification form (if they are different things at your facility). The tech is completely out of line for being mad at you for an incorrect count, and for bringing it to the attention of the surgeon. The surgeon has a right to know, so does anesthesia and every other member of that team. An incorrect count is not something you should attempt to cover up. As far as I am concerned an over count is just as disturbing as an undercount. If you don't actually know what the count is, then what is the point of even counting? How would you know at the end of the case whether you were actually over by 2 instruments, or whether there were actually 4 instruments excluded from the original count? If the number of instruments counted is incorrect, then it is simply a bad count. Had I been the nurse in this room, I would have not only asked for a visual inspection of the cavity, but an X-ray to be done before the patient left the room.

The lax attitude of this facility is going to get them into trouble, and the tech should be disciplined (or at least spoken to about her attitude). Before people start jumping up and down about nurses beating on techs I am a card carrying CST as well as a BSN. Personally, in this situation I would write up the tech and the nurse who did the original count. It simply isn't good enough that they both missed those instruments and then expected someone else to cover their mistake by not bringing it to the attention of the surgeon. Bad form people, just really bad form.

Stay strong in instances like this one and do the right thing for the patient. It's one thing being a team player, but covering for someone else's incompetence should not be part of being a team player.

[Rose_Queen, BSN, MSN, RN]

I would look up your facility's count policy. Ours is that if the count is wrong- too many or too few of something- we need to take an x-ray and it must be read by a radiologist, not the surgeon. That means even if the surgeon says he's fine with the wrong count, it's our butts if we don't get that x-ray. The only exception is some of the really small suture needles, like an 8-0, that wouldn't show up on x-ray.

Your facility is on a slippery slope- if they're okay having too many instruments (how do we know there weren't more that were missed in the initial count?), are they eventually going to be okay with missing a sponge but checking the surgical site? We've had a surgeon twice reopen an incision to find a sponge, declare it not there, and we get an x-ray- there it is, hiding behind the liver. Think of the complications that patient could have had if we hadn't taken the x-ray!

[alovelymother]

Even if the count sheet was incorrect that should have been caught during the initial count. Your scrub tech was out of line for being angry when one of her main responsibilities is to ensure a correct count.

At my facility an incorrect count requires an X-ray before the patient leaves the table. I think you should be hard nosed when it comes to the counts. You might hear grumbling now but that's nothing compared to what you would feel if anything was left in the patient.

[HollywoodDiva]

Read your policy for that facility and I honestly would have asked for an X-ray and then write out an incident report and immediately talk to the director. I write up scrubs that don't like doing counts. Remember in a court of a law you will have to answer for your decisions and actions. Your license and your livelihood...even if it ****** anyone off you must do right by your patient ultimately. I know so many nurses who were non-chalant about instrument counts and one in which an instrument was left in for 5 months who now has to go to court and explain themselves. ALWAYS do what is right.

[lockheart678]

That scrub tech was out of line and your preceptor should have backed you up and covered everything with you that you're supposed to do in a situation like that. I've seen a lot of people who were too lax because we had too many of something at the end, and I would call the shots and tell the surgeons we had to get an x-ray due to policy. I'm not taking any chances that something else was missed in our initial count. To me, a wrong count is a wrong count. Sure, my surgeons would get ticked sometimes, but they knew exactly why it needed to be done and they always liked working with me because they knew I did a good job taking care of that patient. I've also run into the occasional tech who would get mad at me because I demanded another count. For some odd reason, some of these people think we only need to do one closing count, even on an open belly case. Any time someone would give me crap about it, I went straight to my supervisor as soon as the case was done. They can get mad all the want, but they need to do their job.