instrument count records

stevierae · Aug 13, 2004

By the way shobedo -- I have a 20 pound mutt -- all cute and puppyish looking who is certain that she is a doberman:rolleyes: !! The quintesential guard dog!! She is finding it difficult to convince the rest of the dogs in the neighborhood of that though -- they all just think she's a sissy dog -- but we know that inside that little body -- somewhere -- is a "real dog!!" :chuckle

And what about those cute little miniature Pinschers (sp?)

They are so adorable!!

stevierae · Aug 13, 2004

You know, seriously--maybe streamlining the instrument trays would help--a LOT.

I have seen open shoulder trays that have ancient--ANCIENT--retractors that we used to use for open Putti-Platts or Bankharts in the early '70s. Freakin' Bankhart retractor, in the set; should be in a museum. Why, pray tell, is all that stuff still in there, when everything is pretty much arthroscopic or minimal incision surgery these days? I can remember people scofffing at the idea that a rotator cuff repair could be done arthroscopically--now it's pretty much standard of care--yet we still have the huge trays of instrments that really are better off in museums--they are part of history.

I know, I KNOW, you say, "Well, why would you count on a shoulder anyway--it's not like it's a body cavity--" well, I agree, but try telling that to the people who are so by the book that they insist on an instrument count no matter WHAT the case is--could be a tendon repair of a finger, and we are counting instruments because of how they interpret "policy--" never mind critical thinking and common sense.

What really needs revamping are vascular trays--vascular clamps nobody uses; still in the set because some guy who died in 1979 used to use them. 32 bulldogs in a tray when 4 would suffice. (I know 4 would suffice, because when I was in the Navy they would "disappear" for use as roach clips :roll and we got along just fine with the 2 straight, 2 curved that remained.

Or crani trays that still have gigli saw handles and a Hudson brace and bits--nobody has USED them since 1981, when the "old man" neurosurgeon retired, and there are no Gigli saw blades for them, anyway--they haven't been ordered or stocked since that time.

And what about all the sharp towel clips in major and minor trays? Who even uses them anymore? Nobody, since everybody went to paper drapes in 1980 or earlier.

carcha · Aug 14, 2004

I feel your argument is not valid for todays litigious society and nursing practice. Like you I have worked in the OR for many many years, in every speciality, in many ORs, in different hospitals, in several european counties and on different continents. While common sense does have to play a part in all our actions following correct policy and procedure is what ultimately protects us from our own downfall. In a case such as you describe, a tearing of the aorta, if I had to open clamps intra op my common sense tells me to immediately grab the necessary clamps or whatever give them to the surgeon, carry on with the job at hand until the patient is out of danger. My training, knowledge, experience then tells me to then check the set with the runner. This takes one to one and a half minutes and at no time do I take my attention away from the surgical field. As for the surgeon thinking I am not paying attention to what is going on if he needs his suture loaded. I dont give a rats a£$ what he thinks as I do know what he'll think if we both have to appear before a coroner if a patient is harmed due to a retained instrument. In such a case as you describe where there is a certain amount of chaos I would have thought it even more important to ensure all instruments are accounted for prior to closing. Counting instruments should be a must for all scrub nurses just as counting sponges or sutures is. There is no excuse for not doing so. Any of us no matter how experienced or careful is at risk of making a mistake. To me the count says, "I have tried my best to minimise that posibility", thats all we can do.

x3_mom · Aug 15, 2004

I also believe that the count is of upmost importance. But in cases that go "way south" and I did not have time to count the instruments intra-op as the trays were opened, then I would request an x-ray. The Circulator can call for a flat plate once everything settles down. The Radiology Tech can shoot the film and go develop it while the surgeon begins closing. It only takes a few minutes to shoot and the Radiology Tech is usually back with the film before the surgeon has the first layer completely closed.

This has saved quite a few OR personnel from leaving something behind.

wannabenursetx · Aug 15, 2004

Was recovering from my c-section three years ago, when a nurse frantically came into my room, telling me they were going to have to send me to x-ray because they were missing an instrument! The thought of having to go back into surgery didn't please me one bit:chuckle - but, luckily, she came back in a few minutes later and said "never mind, we found it!" I didn't bother to ask where - I was so relieved it wasn't inside me!:rotfl:

stevierae · Aug 17, 2004

I feel your argument is not valid for todays litigious society and nursing practice. Like you I have worked in the OR for many many years, in every speciality, in many ORs, in different hospitals, in several european counties and on different continents. While common sense does have to play a part in all our actions following correct policy and procedure is what ultimately protects us from our own downfall. In a case such as you describe, a tearing of the aorta, if I had to open clamps intra op my common sense tells me to immediately grab the necessary clamps or whatever give them to the surgeon, carry on with the job at hand until the patient is out of danger. My training, knowledge, experience then tells me to then check the set with the runner. This takes one to one and a half minutes and at no time do I take my attention away from the surgical field. As for the surgeon thinking I am not paying attention to what is going on if he needs his suture loaded. I dont give a rats a£$ what he thinks as I do know what he'll think if we both have to appear before a coroner if a patient is harmed due to a retained instrument. In such a case as you describe where there is a certain amount of chaos I would have thought it even more important to ensure all instruments are accounted for prior to closing. Counting instruments should be a must for all scrub nurses just as counting sponges or sutures is. There is no excuse for not doing so. Any of us no matter how experienced or careful is at risk of making a mistake. To me the count says, "I have tried my best to minimise that posibility", thats all we can do.

Well, don't get me wrong--I do believe that in today's increasingly litigous society people are always looking for a way to sue anybody they can, regardless of whether actual DAMAGES were incurred--witness the woman with lung CA who we discussed earlier who lived an extra 7 years after lung resection; however, when her body was donated to medical science, a blue towel was in her chest. Did the blue towel cause injury or contribute to her death? No. Hence, no damages, no causation= no case. They may eventually settle for the nuisance value of the case, but, the fact is, this does not constitute medical malpractice. Does it constitute nursing negligence/malpractice? Not in a court of law, since there were no damages--however, the circulator, not the surgeon, is the one who will be leaned on most heavily in the lawsuit--and, after all, the circulator is responsible for ensuring that the count is correct and reporting it to the surgeon as such--and she told him it was correct, apparently. The old days of "Surgeon as capatain of the ship, nurse as borrowed servant" are gone, and good riddance to those days. We all need to be held accountable for our own actions.

And I do count instruments at facilities where it is required. But at facilities where it is not required, I do not, and I am glad for the opportunity not to do so.

And I still--and maybe I am stubborn--think that we as more experienced RNs need to start educating, (or maybe encouraging is a better word,) the younger staff not to put so much junk up on their Mayos. I have to admit, I haven't done so yet, and I doubt they would listen anyway--and they really do have the right to set up their Mayos any way they feel like--in fact, I will not work in an operating room in which everybody is required to set up his Mayo and back table in the identical fashion, according to some master plan, (created by management) as if they were robots--there are some like that here in Oregon--

I'm telling you, I really think that a post-op flat plate abdomen, before the patient leaves the OR, is the way to go--and from what I hear from other travelers, it's fairly common. I wish it would catch on universally.

We HAD to have been doing SOMETHING right in the '70s, '80s and early '90s when we did not do instrument counts--yet no one ever heard of a retained instrument--what was it that we did right? The only possible thing it could be is that scrubs were more careful about accounting for what was up on their Mayo at all times, and ensuring that what was handed to the surgeon was eventually HANDED BACK--the same way we account for needles--exchanged them on a one-for-one basis. Surgery these days is not any more complicated than it was in the '70s and'80's--if anything, with minimal incision surgery and a larger variety of endoscopic instruments and staplers, it is far LESS complex.

We no longer (probably since the late '90s) allow blue towels to be placed in a body cavities, no matter where I've worked--there just really is no good reason to justify doing so--we use lap tapes, since that's what they are intended for--and, after all, laps are X-ray detectable--blue towels are not.

I think I will start encouraging my scrubs to put a max of 12 instruments on their Mayos at any given time and give me feedback on how it works out for them. I know it works for me. Who was it--Thoreau, I think--who said, "Simplify. Simplify." That's a good philosophy to live by.

carcha · Aug 17, 2004

I cannot agree with you more about the mayo stand , however I find that with the shortage of OR staff, especially here in London, there is a HUGE turnover of experienced RN's as their so fed up with the stress. As a result we get a lot of inexperienced grads who are great but who are learning on the job.. This results in inexperienced teaching inexperienced. I have found however that only one session on what should be on a mayo stand, and my teaching and training was like yours in enough to make them understand what a mayo stand is for. Another thing Stevierae is that the mayo stand is gradually being faded out in certain ORs here so that may account for the lack of understanding.

Now re the instrument count. Do you really feel taking an x-ray is appropriate when a scrub nurse has enough time to count instruments?. Seems like a waste of money to me. Also, re your working in OR's that do not count instruments. About 10 years ago I worked in a place like that . No instrument counts, baseline, first, second. This was on the instructions of the head nurse. Well as you can imagine one day the sterile dept rang to say an instrument tray was missing an instrument . what was the head nurses reaction. She interviewed the scrub, circulator and everyone else who was involved to find out if the instrument was there in the "counts", the same counts she forbade us to do. She covered her *** alright. The instrument was found but all of us learned a lesson. Do the counts!

stevierae · Aug 17, 2004

Another thing Stevierae is that the mayo stand is gradually being faded out in certain ORs here so that may account for the lack of understanding.

Huh, what do they use instead of a Mayo stand? Do you work directly from your backtable, or what? That's interesting--I am always willing to learn new tricks...

Do they seriously use travelers in London? I am serious about doing a travel assignment there if they do--that would be so cool...

carcha · Aug 18, 2004

We dont use a mayo stand for most cases, just the odd one or two. I guess we just adapt to the table we have. As for travellers in London, are you kidding me?. Just register with the NMC in Portland Place in London, you dont need to sit any exam or anything Stevierae. Then either come as an agency nurse, we dont use the term travellers, you work as an agency nurse and earn a load more then the permanent staff, or if you want to work as a permanent member of staff you can do that too. The whole of London is continually desperate for staff. A lot of hospitals will offer accomodation so even if you just wanted to spend a few months touring London it would be a paid holiday. And you get all the benefits anyone else here does, sickness, holidays, 7 weeks a year, pension, education courses ect ect. Its great.

stevierae · Aug 18, 2004

We dont use a mayo stand for most cases, just the odd one or two. I guess we just adapt to the table we have. As for travellers in London, are you kidding me?. Just register with the NMC in Portland Place in London, you dont need to sit any exam or anything Stevierae. Then either come as an agency nurse, we dont use the term travellers, you work as an agency nurse and earn a load more then the permanent staff, or if you want to work as a permanent member of staff you can do that too. The whole of London is continually desperate for staff. A lot of hospitals will offer accomodation so even if you just wanted to spend a few months touring London it would be a paid holiday. And you get all the benefits anyone else here does, sickness, holidays, 7 weeks a year, pension, education courses ect ect. Its great.

I am there. No kidding; this is where I want to take my next travel assignment.

I just spent the weekend in Victoria, British Columbia and it looks EXACTLY as I imagine London and other English cities to look--flowers EVERYWHERE--and not just plain old everyday flowers, but breathtakingly spectacular flowers as one imagines make up the famous English gardens--roses, hibiscus, all kinds of lavender....

carcha, I may p.m. you after I check out and register with the NMC--I wonder if they pay for the round trip airline tickets? Heck, I might not want to come back, but have a husband, kids and pets who are somewhat fond of me--not to mention my dragonboat team...