Surgeon closing before re-count complete

[NewOR-RN]

Has anyone experienced a surgeon continuing to close, and actually completing the last stitch (instead of waiting) after an incorrect count had been announced and a recount between the circulator and tech was in process?

X-ray taken, patient is fine. Surgeon acting oblivious, stated that he was unaware count was not correct.

[TakeTwoAspirin, MSN, RN, APRN]

I've seen this many times. The reality is that MOST of the time the missing item is found on the re-count and/or after a bit of searching around in the bins/floor/under feet. If the surgeon waits for the re-count, the surgery takes longer. Many surgeons will continue to close, knowing that if there is a problem that is not resolved they can open the incision more quickly than they took to close the incision. It's all about the math. As for him saying he didn't know the count was correct, yeah, right! The facility policy probably says very specifically that closure must wait for the re-count, which is why he is saying he didn't know. Truth is, he knew and took a calculated risk to continue.

[NewOR-RN]

I've seen this many times. The reality is that MOST of the time the missing item is found on the re-count and/or after a bit of searching around in the bins/floor/under feet. If the surgeon waits for the re-count, the surgery takes longer. Many surgeons will continue to close, knowing that if there is a problem that is not resolved they can open the incision more quickly than they took to close the incision. It's all about the math. As for him saying he didn't know the count was correct, yeah, right! The facility policy probably says very specifically that closure must wait for the re-count, which is why he is saying he didn't know. Truth is, he knew and took a calculated risk to continue.

Thank you for the reply. Was risk management called? Is this not considered to be a sentinel event, in general? At my facility it is, even though the instrument was accounted for after the close. At the time of close, the count was incorrect and he completed anyway.

[Rose_Queen, BSN, MSN, RN]

Same as TakeTwoAspirin here. Surgeons keep closing because of course whatever it is we're looking for is never in the patient . Although if I were to compare the number of wrong counts we've had vs. the number of patients we've had to reopen after an x-ray, the first number would be fairly large and the second would be less than the fingers on one hand (personally for me it's 0, I know of 1 where x-ray confirmed that what was missing was indeed in the patient. Usually we either find a sponge hiding in the same spot as another in the sponge counter bag, on the floor, or in a fold of the drapes. If it's a needle, it's usually somewhere on the floor, hiding in the drapes, or somehow got doubled up in the needle counter. Instruments are usually on the floor, kicked under something so they're out of the way but nobody told the circulator so they could pick it up and have it in sight for the final count.

As long as the count is good before the patient leaves the room, we don't do an incident report unless we've taken an x-ray. Usually we find whatever it is as x-ray is rolling the machine through the door.

[TakeTwoAspirin, MSN, RN, APRN]

I've never completed an incident report or involved risk management because we've never had an incident where we didn't find the object prior to the patient leaving the OR. Of course, if we can't find it and we need an x-ray to distinguish whether or not it is in the patient, then a report must be done.

How to say this? There are often times when what is actually done is not what is in the procedure manual. I'm not saying I condone what this or any other surgeon does when they ignore the circulator, but instances such as this are a fact of life. If no harm is done then I don't see any reason to complete a stack of paperwork for what turns out to be a non-event. Now if the count is incorrect, the surgeon continues to close, it is still correct and the patient is rolling out of the OR door (with a still incorrect count that the surgeon refuses to acknowledge), then that is a completely different situation.

[kguill975, MSN, APRN, NP]

If a patient is closed, and there was a retained object, it's a sentinel event and is reportable. It doesn't matter that it was caught and retrieved before leaving the OR. If the patient was closed, and the foreign object was found outside of the body, then you were lucky. Everyone gets that question on CNOR, and most people miss it.

[cherston1]

Basically what you need to do is follow Hospital policy regardless of what you think. Another thing to do is also check the policy of AORN which for most is considered the gold standard of nursing operating room practice. As long as you are following hospital or AORN standards you are fine. If you don't, well you are ripe for an attorney later. Remember, it is YOUR license on the line because the surgeon will blame THE NURSE or the SCRUB. If this continues to happen, you might need to report it to your manager if you can't address the surgeon personally about this. Something other hospitals have done is to not pass closing suture to the surgeon until your first count is done, but that can be a problem. Other hospitals have mandated an x-ray on all open cavity patients regardless of if the count is correct. Counts also go faster if your scrub is organized. It's a scrubs responsibility to keep track of instruments that go into the patient, so if one is missing it is the scrub who has not kept track very well. I can say that because I used to be a scrub. But I agree that any time you have a count that is off, it is an event and needs to be reported. If it is not reported, your surgeon will continue to ignore counts.

Just remember to always follow hospital policy and you won't be involved in a trial and suddenly be with out a license. Also if an event happens, DONT talk to anyone about what happened. Since anything you say to someone else can be used in a court against you. As can what you write. So also be careful about the notes you keep after an event.

[nurseboudin]

I am an OR manager, and I've been involved in two sentinel events to conduct a root cause analysis. It doesn't matter if you leave the room or not. A retained item occurs after final wound closure. In both events we reviewed, the patient wasn't out of the room AND was not woken up...but the physician had to go back in to retrieve the item.

It's not practical to leave a wound wide open while counts and recounts are done, nor is it the safest practice. Our policy clearly states that wound closure may begin as final count is being done, but cannot be completed until the surgical team has confirmed that all counts are correct. The rule boils down to this: Don't throw the last stitch or staple until counts are finalized.

[springchick1, ADN, RN]

The surgeon may finish closing and break scrub but we don't take any if the drapes off or wake the patient up until we hear from the radiologist that there is nothing in the patient.