Adherence to count policy in surgery

Health and Disability Commissioner Anthony Hill today released a report finding a medical centre and surgeon in breach of the Code of Health and Disability Services Consumers’ Rights for the surgical care provided to a woman.

Four days after the woman’s surgery at the medical centre’s onsite theatre, the woman discovered a gauze swab that had been inadvertently left inside her operation site.

Mr Hill found that the theatre nurses did not complete an initial count of swabs and sharps (anything sharp used during a procedure, such as needles) before the surgery began, record that the gauze swab had been inserted during the surgery, or complete a closing count at the end of the surgery. The surgeon then failed to confirm the status of the count at the end of the surgery, as required by the medical centre’s count policy.

"A surgical count-in and count-out process is an important communication and team-work tool, which ensures the safety of the patient in the operating room. I am concerned that this process was carried out poorly by staff… As the senior clinician in the room, it was the surgeon’s responsibility to ensure the counting procedures were adhered to," Mr Hill said.

Mr Hill also found the medical centre’s count policy lacked sufficient detail, and that staff were unsure about their roles and responsibilities in the counting process.

"This case is an example of the need to be constantly vigilant to ensure communication is effective, policies are clear, and that they are complied with."

Mr Hill recommended that the medical centre and surgeon provide a written apology to the woman, and that the medical centre report on its use of the Surgical Safety Checklist and carry out an audit on compliance with its count policy.

The full report for case 17HDC02250 is available on the HDC website.