Count In Progress

Medical errors related to interruption of critical tasks are well documented in the clinical setting including the operating room.  Numerous strategies have successfully reduced interruptions during medication administration including the use of attention attention-getting vests, lanyards, or sashes along with signage alerting those in close proximity to the critical nature of medication administration.

The surgical count is the front line of defense against retained surgical items (RSI).  The Count In Progress project adopted the concept of visible signage into the operating room in the form of a bright orange visual indicator with ‘Count In Progress’ boldly printed across it.  The sterile visual indicator announcing the surgical count process is placed directly on the surgical field during the final count thus alerting direct providers as well as charge nurses and ancillary staff of the count process. Limiting the detrimental effects of interruptions during the final surgical count improves the surgical count process making it more effective and efficient thus improving patient outcomes by preventing exposure to unintended radiation, avoiding extended anesthetic and operative times, and potentially averting retained surgical items.

The purpose of this innovation project was to improve counting performance by visually alerting the entire perioperative team when the final count process takes place.  Interruptions during critical tasks result in errors -- This fact has been repeatedly recognized during the task of medication administration in a variety of health care settings.  Medical literature reveals the implementation of an array of interruption management strategies have effectively reduced medication administration errors consequently enhancing the culture of safety. One strategy used in medication administration is a visual indicator alerting others to limit conversations and interruptions while the critical task is performed.

Liberally borrowed from the medication administration techniques, the sterile bright orange visual indicator provides a simple and consistent method to alert perioperative staff in real-time to the count process.  Placed directly onto the surgical field during the count, the visual indicator erases ambiguity by communicating to everyone in the perioperative setting the critical task of the surgical count is taking place.      

All surgical procedures performed at UCSF’s main operating rooms during the three-week trial period whether scheduled or emergent, adult or pediatric, were provided with the orange visual indicator and a data collection sheet in the surgical case cart.  As the trial was voluntary, and although encouraged to use the visual indicator on every surgical procedure, the perioperative staff elected when to display the visual indicator during the closing surgical count process.  The sterile visual indicator was to be opened up and spread upon the sterile field or Mayo stand during the closing count process.  At the conclusion of the count the visual indicator was to be moved away from the sterile field onto the backtable.  The visual indicator could also be displayed during the closure of a cavity within a cavity, during permanent relief counts, or for the skin count. This innovation sought to increase awareness of the count in progress. 

Chief Investigator: 

Margo Peterson, MS, RN, CNOR
Clinical Nurse Supervisor IV
Mt. Zion Operating Room