Lessons from the Field: An Examination of Count Errors in the Operating Theatre

The study was designed to evaluate the frequency and type of count errors, and examine the circumstances under which they occur, in operating theatres in Sydney hospitals. One hundred and forty count errors were documented across seven hospital sites during a three-year period, of which 64% were 'documentation' errors and 36% were 'lost item' errors. The majority of count errors occurred during elective surgery (79%), of up to four hours' duration (74%), and involving just one instrument nurse and one circulating nurse (80%). Perioperative nurses reported that complex surgeries, rushing, instrument handling and team performance issues detracted from their capacity to count and document accurately. The study recommends better management of nurses' fatigue during long and complex surgeries. There is a clear need for increasing the number of circulating nurses for busy lists with multiple, short surgeries, and limiting the number of items added to the sterile field during surgery. Within the busy, pressured surgical team, a whole-of-team commitment to count procedures must be adopted and cooperation and communication must be maintained. While there are set count procedures in place, each operating suite is responsible for encouraging compliance with accepted practice and supporting and sustaining instrument and circulating nurses in their efforts to eliminate count errors.