1. “NOTHING LEFT BEHIND” THE SURGICAL COUNTING in ISRAEL`S O.R A NATIONAL RESERCH EDNA LAVI, RN, ORN, BA RAMBAM HEALTH CARE CAMPUS HAIFA, ISRAEL

2. INTRODUCTION  Mistakes and almost mistakes in surgical counting put the patient’s life at risk.  Patient safety is at the center of the operating room nurse’s philosophy.  It is important to use risk management in the OR routine in order to prevent mistakes in surgical counting.

3. FACTS  There are different interpretations in the recommended practices for surgical counting.  There are great differences in the actual performance of processes.  We have to change certain general guidelines in order to reduce mistakes and almost mistakes in surgical counting.

4. AIM OF RESERCH  Reduce the number of mistakes and almost mistakes in the operating room.  Establish uniform work procedures in all operating rooms in Israel.  Reduce interpretations to written policies.  Assimilate correct work processes.

5. METHODOLOGY  Anonymous research questionnaires included OR nurses from 16 hospitals.  500 questionnaires were distributed.  345 nurses (69%) answered the questionnaires.

6. BASIC ASSUMPTION the possible factors causing mistakes/possible mistakes in the surgical counting are: The human factor. The environment factor. The process's failure.

7. THE QUESTIONNAIRE Included 4 aspects:  Operating room nurses’ beliefs in relation to factors that contribute to the making of mistakes in surgical counting.  nurses’ training and OR seniority in relation to factors that contribute to process failure.  The counting process as it is actually performed.  Documentation in cases of a mistake in counting.

8. RESERCH RESULTS

9. DIVISION OF NURSES ACCORDING TO TRAINING AcademicLicensedRegistered

10. DIVISION OF NURSES ACCORDING TO SENIORITY 30+ YEARS 20-30 YEARS 11-20 YEARS 6-10 YEARS 1-5 YEARS

11. MAPPING THE COUNTING PROCESS

12. MAPPING THE COUNTING PROCESS SPECIAL CASES

13. WHEN THERE IS A COUNTING DISCREPANCY

14. NURSES ATTITUDES - FACTORS CONTRIBUTING TO COUNTING MISTAKES

15. NURSES’ TRAINING AND FACTORS CAUSING COUNTING MISTAKES

16. SUMMARY OF RESULTS A significant difference has been found in the following cases:  The strictness of the count process when there are 2 nurses in the OR.  The count report in nursing documents (less then 80%).  A significant difference in counting in special cases such as fat patients, donation cases, etc.

17.  A different in the items counted.  A reduction in the strictness of reporting during staff changes.  A difference in policy about documentation and X-rays in cases of counting discrepancies.  A difference in actions taken in cases of counting discrepancy. SUMMARY OF RESULTS (cont.)

18. DISCUSSION

19. THE HUMAN FACTOR There is a limit on the human brain and it donates to human error even in such simple acts like counting to ten.

20. THE ENVIRONMENTAL FACTOR  A stressful, complicated, and distraction prone environment in operating rooms may cause a lot of confusion and human error.  Disinformation between O.R staff, because of masks, glasses and other protective equipment causes a failure in communication.

21. THE PROCESS Failures in the process may be caused by:  Deviation in the counting process routine.  Not working according to written policies and procedures.  Nurses’ slackness in process performance.  Inadequate report and documentation.

22. RECOMMENDATIONS  To emphasize the importance of patient safety as a foundation to quality improvement.  To write clear and understandable policies that are not open for personal interpretation.  To establish a risk management system to inspect actual practice.

23.  To create a case study learning system.  To use an ergonomic thinking process aimed at improving and assimilating work and counting processes. RECOMMENDATIONS (cont.)

24. HOW CAN WE DO IT?

25.  Written clear national guidelines and procedures for sponge, sharp and instrument counts that define materials to be counted, the time for counts, and the documentation required.  Periodically refreshing staff knowledge.  Providing an atmosphere of obligation to documentation and reporting.

26. Summary  The safety and welfare of patients during surgical intervention are the primary concerns of peri-operative nurses.  Policies and procedures are designed to ensure the safety of patients and staff and must be followed.

27.  As human beings, we have the potential to make mistakes and injure patients by forgetting foreign bodies in a patient's operative site. Therefore, the counting process must be an integral part of all procedures in the O.R.  A risk management policy ensures safe patient care. Learning from it we can reduce and prevent cases of mistakes and almost mistakes in counting processes.

28. WHAT HAVE WE ALREADY DONE?  We send the research book to the nursing division in ministry of health in order to be a part of the writing regulation committee.  Nursing division in ministry of health opened a course include novice nurses and un-experienced nurses to prepare new generation in OR.  We published our research among head nurses in OR.

29. The point is We want to ensure that every case is preformed safely and that our surgical tools remain where they belong – in the OR and nothing is left behind. IT IS EASY AS 1-2-3