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Instrument Count Sheets and Set Reviews as Patient Safety Tools
PATIENT SAFETY FIRST
Instrument Count Sheets and Set Reviews as Patient Safety Tools JOAN SPEAR, MBA, RN, CNOR, CRCST
I
ncomplete information on instrument count sheets can lead to instrument sets containing incorrect items, resulting in surgeon and staff member frustration as well as delays in surgery. For example, during a myringotomy, a surgeon finds a Bruns curette in the instrument set but no Buck ear curette (Figure 1). In a situation like this, the RN circulator may need to calm the surgeon, obtain an ear curette, and then, after the procedure, investigate why the mistake occurred. In this example, the team tasked with the investigation discovers that the instrument count sheet simply lists “1 curette,” without specifying the type. The new employee who assembled the set had previously assembled a small bone set. After she had removed the myringotomy set from the washer disinfector and found that it lacked a curette, she had simply placed a small bone set curette in the myringotomy set. The team concludes that the count sheet needs more complete information, the sterile processing team needs education, and a process is needed to double-check assembled sets until the
individual assembling the sets has demonstrated the required competencies. The author Peter Sheahan believes that it is important to “absolutely, positively sweat the small stuff.”1(p99) His focus is business, although this mindset can also be applied to the perioperative arena. If perioperative personnel sweat the small stuff (eg, use common nomenclature for the names of instruments), unplanned events such as the preparation of incorrect instruments can be eliminated and personnel can deliver safer patient care. Perioperative personnel may think of the instrument count sheet as simply a tool for sterile processing department (SPD) personnel to ensure the correct instruments are in a set at the time of assembly. Although that is an important function of a count sheet, perioperative personnel should use the same tool to verify the instruments in a set when counting before, during, and at the completion of a procedure. Collaboration http://dx.doi.org/10.1016/j.aorn.2016.10.007 ª AORN, Inc, 2016
588 j AORN Journal
www.aornjournal.org
December 2016, Vol. 104, No. 6
Count Sheets and Set Reviews
Figure 1. A Bruns curette (top) and a Buck ear curette (bottom). Illustration courtesy of Kurt Jones.
can help ensure the instrument count sheet serves as a more robust patient safety tool for surgeons and staff members in both the procedure area and the SPD. In addition, regular review of the names and contents of instrument sets is a related safety tool. Both count sheets and set reviews are important components of the culture of safety in any procedure area. Effective communication begins with the perioperative team and results in increased patient safety.
EFFECTIVE INSTRUMENT COUNT SHEETS The instrument count sheet should contain specific information about the instruments that belong in the set, such as catalog number, vendor, complete description of the items, quantity, and other instructions (eg, a disposable item used with the instrument).2 Using a common language for naming sets and instruments, including descriptions and the instruments’ correct names, renders the information more easily understood. It is not uncommon for instruments to have nicknames. A nickname used in the procedure area, however, may not be the same as the nickname that SPD staff members use. If the RN does not use common language when calling for a replacement instrument, confusion and miscommunication can occur, resulting in a longer procedural time for the patient and a disruption of the normal OR procedure flow. Personnel in some large facilities may call the same instrument by different names depending on the specialty in which it is used. This inconsistency can be confusing to everyone from supply chain personnel to surgeons. Table 1 provides a sample of instrument nicknames from a variety of practice settings. Although personnel in the OR might know an instrument by its nickname, SPD colleagues would need to research the name to determine the specific instrument needed. In Table 2, there is a catalog number included on the count sheet to help identify the instrument. Such an identifier is not
www.aornjournal.org
helpful, however, when an instrument is needed quickly. Table 3 shows what instrument descriptions could look like to reduce confusion. Additional count sheet information might include the total number of actual instruments in the set as well as the number that should be in the set, along with the specific set ID for personnel accountability or system tracking (Figure 2). The landmark report To Err Is Human: Building a Safer Health System,3 issued by the US Institute of Medicine, contains research findings on using standardized procedures to reduce the opportunity for errors; this standardization is also applicable to count sheets. The inclusion of more information on count sheets (eg, specific instruments, quantity required) must be promoted by the procedure area
Table 1. Sample of Instrument Nicknames From a Variety of Practice Settings Instrument Name
Nickname
Allis clamp
Claw
Army-Navy retractor
US retractor
Babcock clamp
Laparoscopic bobcat
Bipolar cord
Gray cord with 3-pin end
Bulldog clamp
DeBakey clamp
Crile clamp
Pean clamp, Kelly
Davidson retractor
Hamburger retractor
DeBakey forceps
Vascular forceps, vascular clamp
Halstead mosquito forceps
Snap, clamp
Hunter uterine curette
Banjo
Lahey retractor
Goiter retractor
Mosquito clamp
Small Crile, fine-tip Crile
Adapted with permission from Forging the Communication Connection. Copyright ª 2016. Pfeidler Enterprises, Aurora, CO.
AORN Journal j 589
Spear
December 2016, Vol. 104, No. 6
Table 2. Example of Count Sheet Containing Catalog Numbers
Table 3. Instrument Count Sheet Descriptions That Reduce Confusion
Item Number
Item Number
Item Description
Weinberg vagotomy retractor; 4ʺ 6½ʺ (Joe’s hoe)
MG491R
Joe’s hoe
BH957R
Rienhoff clamp
BD760R
Cat’s paw
BH957R
Schnidt tonsil forceps; 7¼ʺ (Rienhoff clamp)
BD511R
Small rat tooth forceps
BD760R
Russian forceps; 8ʺ (cat’s paw)
FB400R
Vascular forceps
BD511R
PO212R
Laparoscopic bobcat
Adson forceps with teeth; 4¾ʺ (small rat tooth forceps)
BB074R
Knife handle
FB400R
DeBakey atraumatic forceps; 6ʺ [2 mm] (vascular forceps)
BD700R
Small plastic forceps
PO212R
BT041R
Army-Navy retractor
Babcock grasping forceps, double-action; 5 mm; 310 mm (bobcat)
BC252R
Suture scissors
BB074R
Knife handle #3 with ruler
BD700R
Adson-Brown forceps; 4¾ʺ (small plastic forceps)
BT041R
US Army retractor (Army-Navy retractor)
BC252R
Mayo scissors, straight; 6¾ʺ (suture scissors)
Adapted with permission from Forging the Communication Connection. Copyright ª 2016. Pfeidler Enterprises, Aurora, CO.
team. Count sheets can establish a universal language, guide SPD personnel to assemble sets correctly, and help the procedure area team prevent intraoperative delays and retained surgical items.4 Marty Makary5 discusses how physicians may perform procedures according to personal preference rather than evidence-based research. The same can be said about perioperative teams when they give a nickname to an instrument because of unfamiliarity with or dislike of the catalog name. Frequently, there is no connection between the nickname of the instrument, the set it belongs in, or its intended use; for example, calling an instrument bunny ears because it resembles rabbit ears. Sound rationale should be used when setting the standard for nomenclature.
INSTRUMENT SET REVIEW Perioperative personnel should periodically review instrument sets to determine the appropriate set names, which sets can be used by multiple services, and the total number of sets available, to make evidence-based decisions about increasing inventory to support surgeons or procedures. Considerations for set naming include: the type of use (eg, small bone set, major basic set); the specialty for which it is used (eg, indicated in a code or name); a standard naming format for physician-specific sets and limited specialty sets; and a procedure for creating set names. 590 j AORN Journal
MG491R
Item Description
Adapted with permission from Forging the Communication Connection. Copyright ª 2016. Pfeidler Enterprises, Aurora, CO.
Set content determination is the responsibility of the procedure area team. Often, after the procedure team creates a set all that is required is to add the instruments that are needed by a new surgeon or required for a new technique. The procedure team should review set contents on a regular basis to determine whether the set can be streamlined; if so, the count sheet must be revised because adding instruments directly affects the instrument count process. This is an activity related to prevention of retained surgical items and should be documented as outlined in AORN’s “Guideline for the prevention of retained surgical items.”4 Assessment of instrument sets should begin with gathering data about how frequently individual sets are used. Anecdotal evidence is helpful to determine which sets cause problems when completing counts. Surgeons should be included in the review process to determine which sets they need and whether they believe there are too many instruments in the sets they currently use. Sterile processing personnel should be included to identify sets returned for decontamination with many unused instruments. A systematic process for instrument set and count sheet review should include goals, a process for the review, and identified outcomes. Personnel should review all OR instrument sets annually to validate a need for the set and its contents to
www.aornjournal.org
December 2016, Vol. 104, No. 6
Count Sheets and Set Reviews
Figure 2. An example of a count sheet that could improve communication in the OR. Reprinted with permission from Forging the Communication Connection. Copyright ª 2016. Pfiedler Enterprises, Aurora, CO. determine whether they are correct for current procedures. The team should remove instruments that are no longer needed; such a change supports efficiency in OR procedure set up; clean up; transport to the decontamination area; instrument set decontamination, assembly, and sterilization; transport to storage; and assembly of procedure carts.
basic, plastic). The meetings should not exceed one hour and should focus on
Team
reviewing the count sheet, determining any reconfiguration needed, and outlining next steps; obtaining manager and surgeon approval of any revised count sheets before their implementation; and communicating the plan and implementation to all staff members.
The review team should consist of two OR clinical staff members from each service. These team members are responsible for
Outcomes
involving other clinical staff members and surgeons as needed, communicating to all members of the service regarding progress and planned changes, and communicating with all surgeon stakeholders. In addition, there should be one member from the SPD who is responsible for
providing count sheets, having a set available for review when scheduled, planning implementation of changes, and communicating changes to departments.
Process The SPD and OR team members should determine a start date for the review and select high-volume sets to review first (eg, basic neck, major basic, orthopedic basic, neurosurgery
www.aornjournal.org
The main desired outcomes of instrument set and count sheet review are intended to increase patient safety by reducing the opportunity for a retained surgical item and to create an efficient count process. This includes decreasing the time required to prepare instruments for transport after a procedure; lowering the cost of duplicating sets to increase the availability of sets for patient procedures; and improving systems for all areas involved in transporting, storing, using, and processing instrument sets.
CONCLUSION Creating an effective instrument count sheet and periodically reviewing instrument sets contributes to the safety of every patient who enters a procedure area. Count sheets improve collaboration and communication between the OR and SPD; this, in turn, promotes patient safety by ensuring the correct instruments are available when needed for a patient procedure.
AORN Journal j 591
Spear
References 1. Sheahan P. Flip: How to Turn Everything You Know on Its Head and Succeed Beyond Your Wildest Imaginings. New York: Harper Collins Publishers; 2009. 2. International Association of Healthcare Central Service Materiel Management. Central Service Technical Manual. Chicago, IL: IAHCSMM; 2016. 3. Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Institute Of Medicine. http:// www.nationalacademies.org/hmd/w/media/Files/Report%20Files/ 1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20% 20report%20brief.pdf. Published November 1999. Accessed August 24, 2016. 4. Guideline for the prevention of retained surgical items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:369-415.
592 j AORN Journal
December 2016, Vol. 104, No. 6 5. Makary M. Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care. New York: Bloomsbury Press; 2012.
Joan Spear, MBA, RN, CNOR, CRCST, is a clinical consultant and speaker for JMS Consulting, Westminster, MD. As a consultant and speaker for Aesculap, Inc, Center Valley, PA, Ms Spear has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
www.aornjournal.org
Instrument Count Sheets and Set Reviews as Patient Safety Tools JOAN SPEAR, MBA, RN, CNOR, CRCST
I
ncomplete information on instrument count sheets can lead to instrument sets containing incorrect items, resulting in surgeon and staff member frustration as well as delays in surgery. For example, during a myringotomy, a surgeon finds a Bruns curette in the instrument set but no Buck ear curette (Figure 1). In a situation like this, the RN circulator may need to calm the surgeon, obtain an ear curette, and then, after the procedure, investigate why the mistake occurred. In this example, the team tasked with the investigation discovers that the instrument count sheet simply lists “1 curette,” without specifying the type. The new employee who assembled the set had previously assembled a small bone set. After she had removed the myringotomy set from the washer disinfector and found that it lacked a curette, she had simply placed a small bone set curette in the myringotomy set. The team concludes that the count sheet needs more complete information, the sterile processing team needs education, and a process is needed to double-check assembled sets until the
individual assembling the sets has demonstrated the required competencies. The author Peter Sheahan believes that it is important to “absolutely, positively sweat the small stuff.”1(p99) His focus is business, although this mindset can also be applied to the perioperative arena. If perioperative personnel sweat the small stuff (eg, use common nomenclature for the names of instruments), unplanned events such as the preparation of incorrect instruments can be eliminated and personnel can deliver safer patient care. Perioperative personnel may think of the instrument count sheet as simply a tool for sterile processing department (SPD) personnel to ensure the correct instruments are in a set at the time of assembly. Although that is an important function of a count sheet, perioperative personnel should use the same tool to verify the instruments in a set when counting before, during, and at the completion of a procedure. Collaboration http://dx.doi.org/10.1016/j.aorn.2016.10.007 ª AORN, Inc, 2016
588 j AORN Journal
www.aornjournal.org
December 2016, Vol. 104, No. 6
Count Sheets and Set Reviews
Figure 1. A Bruns curette (top) and a Buck ear curette (bottom). Illustration courtesy of Kurt Jones.
can help ensure the instrument count sheet serves as a more robust patient safety tool for surgeons and staff members in both the procedure area and the SPD. In addition, regular review of the names and contents of instrument sets is a related safety tool. Both count sheets and set reviews are important components of the culture of safety in any procedure area. Effective communication begins with the perioperative team and results in increased patient safety.
EFFECTIVE INSTRUMENT COUNT SHEETS The instrument count sheet should contain specific information about the instruments that belong in the set, such as catalog number, vendor, complete description of the items, quantity, and other instructions (eg, a disposable item used with the instrument).2 Using a common language for naming sets and instruments, including descriptions and the instruments’ correct names, renders the information more easily understood. It is not uncommon for instruments to have nicknames. A nickname used in the procedure area, however, may not be the same as the nickname that SPD staff members use. If the RN does not use common language when calling for a replacement instrument, confusion and miscommunication can occur, resulting in a longer procedural time for the patient and a disruption of the normal OR procedure flow. Personnel in some large facilities may call the same instrument by different names depending on the specialty in which it is used. This inconsistency can be confusing to everyone from supply chain personnel to surgeons. Table 1 provides a sample of instrument nicknames from a variety of practice settings. Although personnel in the OR might know an instrument by its nickname, SPD colleagues would need to research the name to determine the specific instrument needed. In Table 2, there is a catalog number included on the count sheet to help identify the instrument. Such an identifier is not
www.aornjournal.org
helpful, however, when an instrument is needed quickly. Table 3 shows what instrument descriptions could look like to reduce confusion. Additional count sheet information might include the total number of actual instruments in the set as well as the number that should be in the set, along with the specific set ID for personnel accountability or system tracking (Figure 2). The landmark report To Err Is Human: Building a Safer Health System,3 issued by the US Institute of Medicine, contains research findings on using standardized procedures to reduce the opportunity for errors; this standardization is also applicable to count sheets. The inclusion of more information on count sheets (eg, specific instruments, quantity required) must be promoted by the procedure area
Table 1. Sample of Instrument Nicknames From a Variety of Practice Settings Instrument Name
Nickname
Allis clamp
Claw
Army-Navy retractor
US retractor
Babcock clamp
Laparoscopic bobcat
Bipolar cord
Gray cord with 3-pin end
Bulldog clamp
DeBakey clamp
Crile clamp
Pean clamp, Kelly
Davidson retractor
Hamburger retractor
DeBakey forceps
Vascular forceps, vascular clamp
Halstead mosquito forceps
Snap, clamp
Hunter uterine curette
Banjo
Lahey retractor
Goiter retractor
Mosquito clamp
Small Crile, fine-tip Crile
Adapted with permission from Forging the Communication Connection. Copyright ª 2016. Pfeidler Enterprises, Aurora, CO.
AORN Journal j 589
Spear
December 2016, Vol. 104, No. 6
Table 2. Example of Count Sheet Containing Catalog Numbers
Table 3. Instrument Count Sheet Descriptions That Reduce Confusion
Item Number
Item Number
Item Description
Weinberg vagotomy retractor; 4ʺ 6½ʺ (Joe’s hoe)
MG491R
Joe’s hoe
BH957R
Rienhoff clamp
BD760R
Cat’s paw
BH957R
Schnidt tonsil forceps; 7¼ʺ (Rienhoff clamp)
BD511R
Small rat tooth forceps
BD760R
Russian forceps; 8ʺ (cat’s paw)
FB400R
Vascular forceps
BD511R
PO212R
Laparoscopic bobcat
Adson forceps with teeth; 4¾ʺ (small rat tooth forceps)
BB074R
Knife handle
FB400R
DeBakey atraumatic forceps; 6ʺ [2 mm] (vascular forceps)
BD700R
Small plastic forceps
PO212R
BT041R
Army-Navy retractor
Babcock grasping forceps, double-action; 5 mm; 310 mm (bobcat)
BC252R
Suture scissors
BB074R
Knife handle #3 with ruler
BD700R
Adson-Brown forceps; 4¾ʺ (small plastic forceps)
BT041R
US Army retractor (Army-Navy retractor)
BC252R
Mayo scissors, straight; 6¾ʺ (suture scissors)
Adapted with permission from Forging the Communication Connection. Copyright ª 2016. Pfeidler Enterprises, Aurora, CO.
team. Count sheets can establish a universal language, guide SPD personnel to assemble sets correctly, and help the procedure area team prevent intraoperative delays and retained surgical items.4 Marty Makary5 discusses how physicians may perform procedures according to personal preference rather than evidence-based research. The same can be said about perioperative teams when they give a nickname to an instrument because of unfamiliarity with or dislike of the catalog name. Frequently, there is no connection between the nickname of the instrument, the set it belongs in, or its intended use; for example, calling an instrument bunny ears because it resembles rabbit ears. Sound rationale should be used when setting the standard for nomenclature.
INSTRUMENT SET REVIEW Perioperative personnel should periodically review instrument sets to determine the appropriate set names, which sets can be used by multiple services, and the total number of sets available, to make evidence-based decisions about increasing inventory to support surgeons or procedures. Considerations for set naming include: the type of use (eg, small bone set, major basic set); the specialty for which it is used (eg, indicated in a code or name); a standard naming format for physician-specific sets and limited specialty sets; and a procedure for creating set names. 590 j AORN Journal
MG491R
Item Description
Adapted with permission from Forging the Communication Connection. Copyright ª 2016. Pfeidler Enterprises, Aurora, CO.
Set content determination is the responsibility of the procedure area team. Often, after the procedure team creates a set all that is required is to add the instruments that are needed by a new surgeon or required for a new technique. The procedure team should review set contents on a regular basis to determine whether the set can be streamlined; if so, the count sheet must be revised because adding instruments directly affects the instrument count process. This is an activity related to prevention of retained surgical items and should be documented as outlined in AORN’s “Guideline for the prevention of retained surgical items.”4 Assessment of instrument sets should begin with gathering data about how frequently individual sets are used. Anecdotal evidence is helpful to determine which sets cause problems when completing counts. Surgeons should be included in the review process to determine which sets they need and whether they believe there are too many instruments in the sets they currently use. Sterile processing personnel should be included to identify sets returned for decontamination with many unused instruments. A systematic process for instrument set and count sheet review should include goals, a process for the review, and identified outcomes. Personnel should review all OR instrument sets annually to validate a need for the set and its contents to
www.aornjournal.org
December 2016, Vol. 104, No. 6
Count Sheets and Set Reviews
Figure 2. An example of a count sheet that could improve communication in the OR. Reprinted with permission from Forging the Communication Connection. Copyright ª 2016. Pfiedler Enterprises, Aurora, CO. determine whether they are correct for current procedures. The team should remove instruments that are no longer needed; such a change supports efficiency in OR procedure set up; clean up; transport to the decontamination area; instrument set decontamination, assembly, and sterilization; transport to storage; and assembly of procedure carts.
basic, plastic). The meetings should not exceed one hour and should focus on
Team
reviewing the count sheet, determining any reconfiguration needed, and outlining next steps; obtaining manager and surgeon approval of any revised count sheets before their implementation; and communicating the plan and implementation to all staff members.
The review team should consist of two OR clinical staff members from each service. These team members are responsible for
Outcomes
involving other clinical staff members and surgeons as needed, communicating to all members of the service regarding progress and planned changes, and communicating with all surgeon stakeholders. In addition, there should be one member from the SPD who is responsible for
providing count sheets, having a set available for review when scheduled, planning implementation of changes, and communicating changes to departments.
Process The SPD and OR team members should determine a start date for the review and select high-volume sets to review first (eg, basic neck, major basic, orthopedic basic, neurosurgery
www.aornjournal.org
The main desired outcomes of instrument set and count sheet review are intended to increase patient safety by reducing the opportunity for a retained surgical item and to create an efficient count process. This includes decreasing the time required to prepare instruments for transport after a procedure; lowering the cost of duplicating sets to increase the availability of sets for patient procedures; and improving systems for all areas involved in transporting, storing, using, and processing instrument sets.
CONCLUSION Creating an effective instrument count sheet and periodically reviewing instrument sets contributes to the safety of every patient who enters a procedure area. Count sheets improve collaboration and communication between the OR and SPD; this, in turn, promotes patient safety by ensuring the correct instruments are available when needed for a patient procedure.
AORN Journal j 591
Spear
References 1. Sheahan P. Flip: How to Turn Everything You Know on Its Head and Succeed Beyond Your Wildest Imaginings. New York: Harper Collins Publishers; 2009. 2. International Association of Healthcare Central Service Materiel Management. Central Service Technical Manual. Chicago, IL: IAHCSMM; 2016. 3. Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Institute Of Medicine. http:// www.nationalacademies.org/hmd/w/media/Files/Report%20Files/ 1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20% 20report%20brief.pdf. Published November 1999. Accessed August 24, 2016. 4. Guideline for the prevention of retained surgical items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:369-415.
592 j AORN Journal
December 2016, Vol. 104, No. 6 5. Makary M. Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care. New York: Bloomsbury Press; 2012.
Joan Spear, MBA, RN, CNOR, CRCST, is a clinical consultant and speaker for JMS Consulting, Westminster, MD. As a consultant and speaker for Aesculap, Inc, Center Valley, PA, Ms Spear has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
www.aornjournal.org