Factors Contributing to Incorrect Surgical Counts and System-based Prevention Strategies
Keywords:
incorrect count, incident reporting, human factors, human error, surgery, patient safetyAbstract
Background: Retained foreign objects (RFOs) can cause negative outcomes for patients such as infection, increased length of hospitalization, and death. Surgical counts are associated with a reduced likelihood of an RFO but the counting process is complex and prone to human error. To improve count accuracy the risk factors for a discrepancy must be identified so that mitigation strategies can be applied.
Objective: To identify the factors that contribute to surgical count discrepancies in order to provide mitigation strategies that will improve patient safety in the operating room.
Methods: An analysis of a sample of 1067 incident reports describing incorrect surgical counts was conducted. Reports were double-coded, by three specialists, on dimensions that included most likely contributing factor for the discrepancy, type and number of items involved, and actions taken to attempt to reconcile the count.
Results: Needles were most commonly involved in count discrepancies. The next most common was instruments. The most common factors reported as contributing to an incorrect count were item(s) being dropped, item(s) not counted during initial count, large case, packing related issue, and change in procedure. An x-ray was conducted in 71% of the reports but only 25% specified it was located in the operating theatre. Additional search strategies were used in a small proportion of reports and included the use of a magnet and microscope.
Conclusion: Surgical counting is a complex process and, in order to ensure count accuracy, a system-based solution is required. Recommended solutions are provided in order to reduce the likelihood of an error.
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