Surgical Counting

Many state public health departments across the country are

reporting an increase in the amount of retained foreign objects
in patients following surgery. The so-called “Never Event” of an
accidental instrument, sponge, needle, electrode, etc. – being
left inside a patient at the conclusion of a surgery is trending
higher in many reports. In our role as operating room
professionals, it is our job, duty, and prerogative to take on the
task of reducing these instances. In addition to the patient risk
involved with such happenings, fines levied, court cases and
damage of reputation are among the consequences to the
professionals and institutions that come as a result of these
critical mistakes and errors. This course is designed to outline
the process of surgical counting and help nurses and other
surgical professionals eliminate the risk of retained foreign
objects.

Getting Started: Defining the Surgical Count

The surgical count plays a vital role in enabling the
perioperative practitioner to enhance the surgical patient’s
safety. Surgical items such as instruments, swabs and sharps

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used by the surgical team to perform invasive procedures, are
foreign bodies to the patient and must be accounted for at all
times to prevent retention and injury to the patient. Many
would argue that surgical counting is the single most important
aspect of the circulating nurses’ duties. Regardless of whether
this is true or not, surgical counting is undoubtebly one of the
most important tasks of the circulating nurse in the operating
room. In this course, we will discuss counting procedures,
items responsible for being counted, methods of accounting for
sponges, personnel responsible for performing the counts,
recommended time for each count, provide current policy and
procedures for counting, discuss recommended strategies for
incorrect count, and many other topics. This course will
illustrate just how important the surgical count is to a safe
operating room experience and how vital the circulating nurse
is to providing a safe surgical experience.

What is a counting procedure?

A counting procedure is a method of accounting for items put
on the sterile table for use during the surgical procedure.
Sponges, sharps, and instruments should be counted and/or
accounted for on all surgical procedures. This includes any
materials introduced into the patient during the procedure,

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such as rectal or vaginal packs or sterile towels used to pack off
or retain viscera.
The counting of sponges, needles, sharps, instruments and any
other item that could become lost in a patient are crucial to
count. Items are counted before and after use. The types and
numbers of sponges, needles and other sharps, and
instruments vary for each surgical procedure.
The documentation of counts should include the items on the
instrument table at the beginning of the procedure, as well as
those added during the procedure. The count should be
performed audibly and with each sharp visualized by both the
scrub person and the perioperative nurse. The number of
needles should be recorded.
During the procedure, the scrub person should be aware of the
location of sharps on the sterile field. Needles should be
accounted for by the scrub person as they are placed in the
neutral zone on a one-for-one exchange basis when possible.
Subsequent counts should be performed by the scrub person
and perioperative nurse before closure of a body cavity or
deep, large incision, after closure of a body cavity, and at skin
closure. Additional counts should be an element of the hand-
off process when either the scrub person or the perioperative
nurse is permanently relieved by other personnel. In situations
where personnel may be relieved on a temporary basis, the

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verbal hand-off should include a discussion about counted
items. In all situations, it is imperative that two individuals be
involved in the count - one counting, and the other witnessing
that the count is correct. All sharps are retained in the OR
during the surgical procedure. Many institutions have printed
forms to keep track of routinely counted items. Others use
erasable count boards visible to all personnel. Recording the
count is the responsibility of the perioperative nurse.
Depending on institutional polcy and practices, the count sheet
may become part of the patient’s record. To facilitate counting,
needles are counted according to the number indicated on the
package; the scrub person verifies this number with the
perioperative nurse when the package is opened. Used needles
should be kept on a needle pad or counter on the scrub
person’s table. Broken or missing needles must be reported to
the surgeon and accounted for in their entirety.

Do you know your institutions’ policy for incorrect counts?

Each institution should have established policies for dealing
with incorrect counts. Unintentional retention of objects
during surgery has been identified as a “Never Event”.
Institutions are required to adopt a comprehensive strategy to
manage the complexity of this issue. Strategies include several
elements, including: an emphasis of forced communication,

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standard processes, and checklists. In situations where an
incorrect count occurs, the surgeon should be immediately
notified, and a recount should be initiated. Sterile team
members and the perioperative nurse initiate a search of the
sterile and unsterile fields. If the missing item is not revealed
after a recount and search, the surgeon is asked to explore the
wound. If the missing item is still not found, agency policy may
dictate that an x-ray film be taken. Documentation of these
activities should be completed according to institutional policy
and procedure.

Put the “count” in accountability

Accountability during the surgical count is a professional
responsibility that rests primarily on both the “scrub person”
and the circulating nurse. The surgeon and patient rely on the
accuracy of this accountability by the team. There are several
reasons why it is important for the scrub and circulating nurse
to count and be accountable for all items used during the
procedure (Table 1.1).

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Table 1.1
Reasons to count - and be accountable - for items used during surgical procedures
Incident Result
Item can be lost in patient’s body Need for additional surgery
Item can be lost in trash or linen Potential harm to other personnel
Item can be lost from inventory, High cost of replacement

Counts are performed for patient and personnel safety,

infection control, and inventory purposes. A needle,
instrument, sponge, tape, or towel left in the wound after
closure is a possible cause for a lawsuit after a surgical
procedure. Containment and control are also important for
infection control.
A retained foreign object made of woven textile is referred to
as a gossypiboma or a textiloma. A foreign body
unintentionally left in a patient can be the source of wound
infection or disruption. The longer the object remains in the
body, the more it incorporates ingrowth of tissue. An abscess
can form, and fistulas may develop between organs. The
foreign body reaction may be immediate or may be delayed for
years. Diagnosis is sometimes difficult and costly, and removal
of the object usually requires major surgery. The literature
reports the removal of some retained sponges through
laparoscopic surgery if they are discovered before adhesions
develop. For an example of a foreign body left in a patient, see
(Photo 1.1.)
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Photo 1.1

A contaminated sponge or needle that is unaccounted for at

the close of procedure could also inadvertently come into
contact with the personnel who clean the room, process
instruments, launder the linens, or transport the trash. Blood
or body fluids are sources of pathogens such as human
immunodeficiency virus (HIV) or hepatitis B virus (HBV). For

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additional learning on bloodborne pathogens, please see the
www.CuttingEdgeCE.com course on “Humans vs. Superbugs”

Inventory control is monitored by accounting for the

instrument set in its entirety. Counting ensures that expensive
instruments including towel clips and scissors are not
accidentally thrown away or discarded with the drapes. Injury
to laundry and housekeeping/environmental services personnel
by the contaminated sharp edges of surgical instruments,
blades, and needles is a risk.

Adverse effects on patients

Based on an ECRI Institute study (2003) that examined
Controlled Risk Insurance Company closed-claims data from
1985-2001, patient deaths due to retained surgical objects
were rare. More common adverse outcomes included:
• Readmission to hospital or prolonged length of stay (59% of cases)
• Second surgery to remove retained object (69%)
• Sepsis or infection (nearly 50%)
• Fistula or small-bowel obstruction (15%)
• Visceral perforation (7%)

One of the patient outcomes identified in the Perioperative

Nursing Data (PNDS) is that “the patient is free from signs and
symptoms of injury due to extraneous objects” (Peterson,
2007). One of the many perioperative nursing activities

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 undertaken to achieve this patient outcome is the performance
of counts to ensure that the patient is free from injuries related
to retained sponges, sharps, or instruments (Patient Safety).
Institutions vary in their policies regarding needle and sharps
counts during operative procedures, but most follow
established procedures based on the Association of
Perioperative Registered Nurses (AORN) Recommended
Practices for Sponge, Sharp and Instrument Counts (AORN,
2009b). (See example 1.1).

Example 1.1
Example of Counting Policy and Procedure
I. OUTCOME STANDARD
A. To ensure that the patient is not injured as a result of a
retained foreign body.
B. To standardize the surgical count process.
C. To account for instruments, reusable and disposable.
D. To assure this surgical count standard also applies to cases of
organ/tissue procurement.

II. POLICY
A. Sponges, sharps and miscellaneous items will be counted pre-
operatively on ALL procedures performed in the operating
room, establishing a baseline for subsequent counts.
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B. An instrument count is indicated when:
a. The surgical wound encompasses a body cavity, such as
abdomen, pelvis, or chest.
b. All procedures in which there is a possibility that an
instrument/sponge could be retained.
c. All procedures in which there is a possibility of progressing
to an open procedure or of extending an incision to allow for an
instrument to be left behind. This includes all laparoscopic,
thorascopic and pelvioscopic procedures.
d. All policies also pertain to pediatric cases.
C. Every OR will have an identical, pre-printed count board
mounted on the wall.
a. The count boards will reflect the required elements
(sponges, sharps, miscellaneous and packed/tucked items. Pre-
printed items include laps, raytecs, rondics, peanuts, knife
blades, atraumatics, free needles, hypodermic needles, bovie
tips and bovie scratchers. All other sponge, sharp and
miscellaneous items will be printed onto small magnets that
can be placed on the board as is appropriate to the procedure.
D. At shift change or at time of permanent relief, at least one
member, but preferably both members from the oncoming
team will conduct an accounting of the counted items, with at
least one member of the outgoing team, preferably the scrub
person, for a hand-off/relief count.

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 E. The RN circulator and scrub person should not be interrupted
during any part of the counting procedure. If they are
interrupted, they must start the count again in the category of
items they were counting when interrupted (e.g., lap tapes,
mayo clamps, etc.).
F. Only X-Ray detectable materials will be used in surgical wounds
or body cavities during surgery. (i.e., Kerlix rolls or non-
radiopaque towels will not be placed/packed in a body cavity
during a procedure).
G. Linen or waste containers will not be removed from the OR
until all counts are completed, resolved and the patient has
been transferred from the operating room.
H. A standardized procedure will be used by all staff members to
record the counts on the count boards, this practice must be
consistent from room to room.

III. PROCEDURE
A. Sponge counts
a. Sponges include but are not limited to Raytec (4x4), Lap
tapes, and Vag tapes, Rondics, Peanuts, Tonsil Sponges and
Cottonoids. Sponges will be counted in order from largest to
smallest.
b. Sponge counts require the full attention of the scrub
person and the RN circulator.

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 c. Sponges will be separated, counted audibly and
concurrently viewed together during all counts. Radiopaque
tags should be visualized by both parties.
d. Sponges will be counted in all procedure where sponges
are on the field. The sponge count will be recorded on the
count board.
e. The scrub person will observe the number of sponges
added on the count board and acknowledge verbally that the
written numbers and the total are correct.
f. Subsequent sponge counts will be performed:
i. When items are added to the field
ii. Before the closure of a cavity within a cavity (e.g., uterus,
bladder)
iii. Before wound closures begin (closing count; if more than
one wound, closing counts must be done independently for
all wounds, if not closed simultaneously).
iv. At skin closure
v. At the time of permanent relief of the RN circulator or the
scrub person; a handoff accounting for the counted items
must be done (change/relief count)
vi. Upon the request of any team member
g. Any package containing an incorrect number of sponges will be
removed from the OR and not used in the procedure.
h. The RN circulator will contain and confine discarded, used
sponges in designated sponge holder bags.

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 i. The sponge holder bags must be visible so that all team
members can view them during the case for the purposes of
blood loss estimation and the verification of counts.
ii. Sponges will be placed in the sponge count bags by type,
i.e., laps in one, raytex in another, with only 5 lap tapes
(one/pocket) or 10 raytex (one/pocket) in each holder.
iii. The scrub person will designate a space on the back table
to maintain all small sponges or miscellaneous items for
counting purposes.
iv. Final accounting of sponges by surgeon, circulator and
scrub will be done during the debriefing. This will be done
before the patient leaves the OR; at that time, all used and
unused sponges should be in the sponge holder bags for
verification.
i. Non-radiopaque gauze dressing materials should be
withheld from the field until the wound is closed or the case
is completed. Dressing sponges that come in the pack should
be left in their plastic zip lock bags and isolated on the back
table away from all other sponges.
B. Sharp Counts:
a. Sharps include but are not limited to scalpel blades,
cautery tips, atraumatic (suture) needles, free needles and
hypodermic needles.
b. Sharp counts require the full attention of the scrub person
and the RN circulator, i.e., the scrub shows the circulator each

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and every sharp item on the field and the circulator
documents the total numbers on the count board accordingly.
c. The scrub person will observe the number of sharps added
on the count board and acknowledge verbally that the written
number and total are correct.
d. Subsequent sharp counts will be performed:
i.When sharps are added to the sterile field
ii.Before the closure of a cavity within a cavity (e.g. bladder
or uterus)
iii.Before wound closure begins (closing count)
iv.At skin closure (final count)
v.At the time of permanent relief or change of shift, a
handoff accounting for the counted items must be done
vi.Upon the request of any team member
vii.Packages of multi-pack needles will be opened, viewed
and counted with both scrub person and circulator, during
the initial count and at the time they are opened until they
are replaced in a sharps container, to avoid inadvertent
injury to a patient or member of the Perioperative team.
viii.The scrub person will maintain an accurate account of all
sharps on the sterile field frequently comparing the field
numbers to those documented on the count board.
ix.All counted sharps should remain within the operating
room and / or sterile field during the procedure.

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 x.Sharps that are contaminated or inadvertently fall from
the field should be retrieved by the circulator, shown to
the scrub person, and isolated from the sterile field. They
should not be disposed of in the sharps container until the
final counts are completed. Sharps that are removed from
the field should be secured safely on a needle magnet or
other appropriate container, so they can be accounted for
and visualized during the final counts.
xi.Pieces of broken sharps must be accounted for in their
entirety
xii.The scrub person will not discard suture packages during a
procedure; all packages will be saved either on the back
table or in the “sterile” paper trash bag on the field.
No packages are to be thrown into the general trash.
Matching empty suture packages to rectify a discrepancy
in a closing needle count is an acceptable method to verify
the closing/final counts, only if all packages have been
saved. If there is any uncertainty, then a radiograph must
be taken. The only exception would be if the needle in
question is known to be 6-0 or smaller, as these may not
be visible on x-ray.
C. Count of Miscellaneous Small Items/Devices
a. Miscellaneous small items/devices are generally
disposable items but may be reusable items that could be
retained in a wound or body cavity if not counted pre-

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 operatively and at the time of closing counts. Most of these
items are not radiopaque.
b. Miscellaneous small items/devices include but are not
limited to: Penrose drains, fogarty/novare inserts, bulldogs,
irrigation tips/adapters, vessel loops, umbilical tapes, suture
bots, tunneller tips/bullets, micro wipes, valvutomes and tips,
silastic tubing, safety pins, rubber bands, GYN prep sponges,
Capio bullets, Lone Star hooks, fish hooks, eye plugs, visibility
background, defogger sponge, hemoclip cartridges, stapler
loads, visceral retainers (fish) and laparoscopic sealing caps.
c. Miscellaneous items require the full attention of the scrub
person and circulator. The scrub person verbally confirms the
number and the type of items that the circulator
acknowledges and documents on the count board (labeled
magnets or hand written labels may be used.)
d. The scrub person will observe the number for
miscellaneous items added on the count board and
acknowledge verbally that the written total number is correct
for each item.
D. Subsequent counts of miscellaneous items will be performed:
a. When items are added to the sterile field
b. Before the closure of a cavity within a cavity (cavity closure
count)
c. Before wound closure begins (closing count: see sponge
count re: multiple wounds)

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d. At skin closure (final count)
e. At the time of permanent relief or change of shift, a hand-
off accounting for the counted items must be done
f. Upon the request of any team member
E. Instrument Counts
a. Instrument counts include all instruments and
miscellaneous pieces associated with that instrument that can
detach/come apart (i.e. wing nuts, suction tips, 2 pieces Poole
suctions, balfour pieces, etc.), contained in an instrument tray
as well separately wrapped instruments that are added to the
sterile field to or during the procedure.
b. Instrument counts require the full attention of the scrub
person and the circulator. They will audibly count and
concurrently view together all instruments and verify the
quantity listed on the instrument count sheet.
c. The practice of counting total number of instruments in
the set is not acceptable.
d. Pre-printed instrument count sheets provided in the set
from central processing will be used to verify the instrument
counts.
e. Instruments added to the sterile field subsequent to the
initial count will be written on the count sheet by the
circulator.
f. The instrument count sheets will be kept in a designated
place in the OR during the case.

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 g. All pieces of a broken instrument will be retained in the OR
during the case.
h. Subsequent instrument counts will be performed:
i. At the time of an addition to the sterile field.
ii. Before each wound after a body cavity is closed
(closing count)
iii. If a closed wound must be re-opened for any reason,
a second closing count will be done at a time of secondary
closure.
iv. At the time of permanent relief or change of shift, a
hand0off accounting the counted instruments must be
done.
v. At the request of any team member.
F. Closing instruments counts are not required on laparoscopic,
pelvioscopic, thorascopic or mediastinoscopies that do not
progress to “open” procedures, despite an initial count being
done.
a. Circulator will document in that closing instrument counts
were not indicated/not applicable because procedure did not
proceed to open.
G. Instrument Count Sheets:
a. The instrument count sheet will be used to record all
instruments and pieces thereof, used in the procedure.
Deviations from the instrument count sheet as well as

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 instruments added to the field will be documented on the
sheets.
b. The OR team will complete the instrument count sheet by
writing names of circulator and scrub person, date, OR# and
time. If the instruments match the count sheet, no comment
is needed. If there are missing instruments, write the number
missing (e.g. -2 Kelly clamps). If additional instruments are
added during the case, write those additions in the “add”
columns on the count sheet.
c. The original count sheets are to remain in the OR with the
instrument sets during the case and returned with the
instrument tray to central processing with any changes noted.

H. Special Considerations:
a. Any item that is tucked or packed into the wound will be
verbally announced by the surgeon and written on the count
board. As items are removed from the wound, they will be
crossed off the “packed” items count.
b. Initial counts will be done completely on the back table.
Counted items should not be brought up to the Mayo or
surgical site until they have been counted.
c. The closing and final count sequences will begin at the
surgical site/patient and the immediate surrounding area.
Proceed to the Mayo stand, to the back table and finally to
items that have been discarded or removed from the field.

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 d. All counts will follow not only a “geographic” sequence but
will follow an “item sequence” as well, following a pre-
determined order:
i.Sponges will be counted from largest (e.g. lap tapes) to
smallest (e.g. peanuts)
ii.Next, sharps will be counted
iii.Third, miscellaneous small items/devices will be counted
iv.Finally, instruments will be counted. Instrument count will
follow the pre-printed count sheet in terms of order.
e. All counted items will remain in the OR for the duration of
the surgical procedure and will either be discarded or
removed from the OR when the patient leaves the room. (No
extraneous sponges or needle packages should be left in the
OR after the patient leaves the room and none should be
present prior to the next patient arriving.
f. The surgeon or scrub person will announce the start of the
wound closure.
g. The surgeon will conduct an exploratory search of the
abdominal and thoracic cavities for counted items before
wound closure begins.
h. If counted items are intentionally left in the wound, the
type of item and the number will be recorded on the
operative record/OPTIME.
i. Contaminated sponges, sharps, miscellaneous items and
instruments must be handled and disposed of according to the

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Blood borne pathogens standard of the Occupational Safety
and Health Administration (OSHA), facility blood borne
pathogen exposure control plan and any other applicable
regulations.
j. The surgeon will verify the counts with the circulator and
the scrub person before exiting the OR by viewing the sponge
count bags to ensure that each pocket of the bag contains a
sponge. This is part of the debriefing to be done at the end of
the procedure.
k. Special attention to instruments must occur during
orthopedic cases utilizing regular or cannulated drills, drill
guides or guide pins. Steps must be taken to ensure these
items or broken pieces of these items are not implanted in the
patient.
i. Orthopedic drills and guide pins will be inspected to
ensure they are intact and not broken. Inspection will
occur prior to insertion and after removal.
ii. Guide pins not intended or approved as an implant
will be removed after use. The cannulated drill/drill guide
will be inspected to verify that nothing remains in the
inner channel. All guide pins inserted into the patient will
be verified as totally removed.
iii. A verbal verification that the above inspections were
done will occur between the surgeon and the scrub both
during and at the end of the case.

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 iv. Any team member can call for an off count at any
time.
l. The OR team will ensure that all pieces of instruments
requiring assembly are accounted for prior to the completion
of the surgical procedure. Special care will be taken when
these instruments are used within an orifice or a deep cavity
to ensure all pieces are secured.
m. Incorrect Counts
i.The circulator will notify the attending surgeon and
the anesthesia care provider when an incorrect count
occurs. The appropriate documentation will be
completed per policy.
1. The nursing staff will immediately make a
thorough search of the room, including the floor,
linen, trash, kick buckets, case cart shelves and empty
instrument containers.
2. The surgeon will immediately stop closing and
explore the wound for any retained items.
3. The scrub person will again search the field and
begin a recount of the missing item.
n. If the missing item (sponge/sharp/miscellaneous item or
instrument) is not accounted for, an X-ray of the wound will
be performed in the operating room before the reversal of
anesthesia. The only exceptions to this would be if the

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 missing item is a small (6-0 or smaller) needle which is not
visible on x-ray.
o. X-rays will be taken for procedures when initial baseline
counts were not obtained (unanticipated open procedures or
emergency procedures when there was not time to count.
The primary responsibility for accounting for all sponges,
sharps, and instruments before, during, and after every surgical
procedure rests with the circulating nurse and scrub person.
Laziness and a cavalier attitude surround the statement, “the
incision is too small to lose anything.” Don’t ever be fooled by
this. It can happen. There are several reasons to count and be
accountable for items used in a surgical procedure.
1. Patients have been known to retain items from a surgical
procedure regardless of the size or location of the surgical site.
This is a serious safety breach that is not excusable.
2. Instruments are costly and should not “vanish into thin air.” It
is a shame that some hospitals x-ray all the trash and have
metal detectors on the doors of the OR. Instruments stuck in
washing machines cause damage to the mechanisms.
Accountability significantly decreases this loss.
3. Many instruments have sharp tips or cutting surfaces. If an
instrument is in the trash or laundry, it can become a source of
injury to unsuspecting housekeepers or laundry workers. This
can result in prolonged illness and possible inability to work.

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Any item put into the patient should be documented as part of
the count and reconciled at the end of the procedure. The
surgeon and first assistant facilitate the count of the items on
the surgical field before closure, however, it is not their job to
perform the actual counts. Because accountability for sponges,
sharps, and instruments is recognized as essential to safe
practice and the Standard of Care, omission of appropriate
counts or a facility’s lack of established procedures for counting
and accountability could result in a serious threat of liability.
There is no excuse for any retained foreign object if the systems
for accountability are followed by the entire team.
The circulating nurse should document in writing the outcome
of the final counts as correct or incorrect and any unusual
incidents concerning them, including the need for a radiograph
to look for a lost item. If a radiograph is taken, the name of the
radiologist and their findings also should be documented. An
incident report should be filed on all counts that remain
unresolved. It is not necessary to indicate the actual number of
sponges or needles used on the OR record. The documentation
of correct or incorrect counts is sufficient. Any questionable
count should be documented as resolved or unresolved act to
whom the event was reported.
The initial count will be done when the tray is assembled. The
person who assembles and wraps items for sterilization will

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 count them in standardized multiple units. Some facilities
enclose a copy of this tray inventory count sheet in the
instrument set. In commercially prepackaged sterile items
(e.g., sponges, disposable towels), this count is performed by
the manufacturer.
The baseline count will be performed during the setup for the
surgical procedure. The scrub person and the circulating nurse
together count all items before the surgical procedure begins
and during the surgical procedure as each additional package is
opened and added to the sterile field. These initial counts
provide the baseline for subsequent counts. Any item
intentionally placed in the wound, such as a towel, is recorded.
A useful method for counting is as follows:
1. As the scrub person touches each item, he or she and the
circulating nurse number each item aloud until all items are
counted. There is no need to be disruptive when performing
this task. Each pack of sponges will be bound with a paper
band that is broken only as each bundle is counted. The
presence of an intact paper band indicates that bundle has not
been counted yet. Count them one bundle at a time.
2. The circulating nurse immediately records the count for each
type of item on the count record or wipe-off board. Preprinted
forms are helpful for this purpose.

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3. Additional packages should be counted away from counted
items already on the table in case it is necessary to repeat the
count or to discard an item.
4. Counting should not be interrupted. The count should be
repeated if there is uncertainty because of interruption,
fumbling, or any other reason.
5. If either the scrub person or the circulating nurse is
permanently relieved by another person during the surgical
procedure, the incoming person should verify all counts before
the person being relieved leaves the room. Personnel who
perform the final counts are held accountable for the entire
count.
The closing count is taken in three areas before the surgeon
starts the closure of a body cavity or a deep or large incision:
1. Field count: Either the surgeon or the assistant assists
the scrub person with the surgical field count. Additional items
(e.g., vaginal or rectal packing, sterile towels used as
intraabdominal packing) are accounted for at this time. This
area should be counted first. Counting this area last could
delay closure of the patient’s wound and prolonged anesthesia.
2. Table count: The scrub person and the circulating nurse
together count all items on the Mayo stand and instrument
table. The surgeon and assistant may be suturing the wound
while this count is in process.

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3. Floor count: The circulating nurse counts sponges and any
other items that have been recovered from the floor or passed
off the sterile field by the scrub person.
The final count is performed to verify any counts and/or if
institutional policy and procedures stipulates additional counts
before any part of a cavity or a cavity within a cavity is closed.
A final count may be taken during subcuticular or skin closure.
The circulating nurse totals the field, table, and floor counts. If
the final counts match the totals on the tally sheet, the
circulating nurse informs the surgeon that the counts are
correct. A count should be reported to the surgeon as correct
only after a physical count by number actually has been
completed. Intentionally exposing the patient to x-rays is not a
replacement for the physical count.
The circulating nurse documents on the patient’s record what
was counted, how many counts were performed and by whom,
and if the counts were correct or incorrect. There is no need to
write all the tallies on the permanent record. A Registered
Nurse should participate to verify that all counts are correct,
but the personnel actually performing the counts are
responsible for the accuracy of the counts. The counting
procedure, the outcome, and participating personnel should be
documented according to institutional policy and procedure.

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 Omitted counts because of an extreme patient emergency
should be recorded on the patient’s record, and the event
should be documented according to institutional policy and
procedure. If a sponge or sponges are intentionally retained for
packing, or if an instrument intentionally remains with the
patient, the number and type should be documented on the
patient’s record. Any time a count is omitted, refused by a
surgeon, or aborted, the reason should be fully documented.
Records can be subpoenaed and admitted as evidence in court.
The accountability for all items used during the surgical
procedure is placed in the scrub person and the circulating
nurse, who jointly perform the counting procedures as defined
by institutional policy and procedure. The surgeon and the first
assistant facilitate the counting process. It is not the job of the
surgeon or the first assistant to actively perform the counts or
sign the count reconciliation sheet.
What do you do if you have an incorrect count?
Specific policies and procedures for any count that is incorrect
should be defined by each institution and should include - but
not be limited to - the following:
1. The surgeon is informed immediately
2. The entire count is repeated

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3. The circulating nurse searches the trash receptacles, under the
furniture, on the floor, in the laundry hamper, and throughout
the room
4. The scrub person searches the drapes and under items on the
table and Mayo stand
5. The surgeon searches the surgical field and wound
6. The circulating nurse should call the immediate supervisor to
check the count and assist with the search.
7. After all search options have been exhausted, policy should
stipulate that a radiograph film be taken before leaving the OR.
The surgeon may wish a radiograph be taken at once, with a
portable machine, to determine whether the item is in the
wound. Alternatively, the surgeon may prefer to complete the
closure first because of the patient’s condition or because there
is reasonable assurance, based on wound exploration that the
item is not in the patient. Unfortunately, patients’ incisions
have been reopened after complete closure to retrieve objects,
such as sponges.
8. The circulating nurse should write an incident report and
document on the OR record all efforts and actions to locate the
missing item, even if the item is located on the radiograph. This
report has legal significance for verification that an appropriate
attempt was made to find the missing item. If the item is not
found on the radiograph, the report is brought to the attention

29
of the personnel the need for more careful counting and
control of sponges, sharps, and instruments.

Sponges are used for absorbing blood and fluids, protecting

tissues, applying pressure or traction, and for blunt dissection.
Many different types of sponges are available. All sponges on
the sterile table and field should be radiopaque. A radiopaque
thread or marker made of a barium substance is incorporated
into commercially manufactured sponges.
1. Gauze sponges are supplied sterile, precounted, and
folded. These are also called Raytec or Raytex sponges. All
are packed in groups of 10 and bound with a paper band.
2. Laparotomy tapes, usually called “lap tapes”, are used for
retaining the viscera and keeping them moist and warm. The
lap tapes have a loop of blue twill sewn on one corner. A
small radiopaque marker is sewn into one corner of the tape.
Lap tapes are packaged in groups of five.
3. There are a few different types of dissecting sponges.
Peanut sponges are very small and are used for blunt
dissection or absorption of fluid in delicate procedures. They
are packaged in groups of five. Tonsil sponges are soft, round
gauzes. Tonsils are packages in groups of five.
4. Cottonoids or “patties” are compressed absorbent
rectangles/squares. They are packaged in groups of ten.

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 Because of the importance of the topic,
let’s reiterate the steps in counting sponges!
Radiopaque, radiograph-detectable gauze sponges, tapes,
towels, dissecting sponges, and cottonoid patties are counted
in multiples of 5 to 10 per package. The types of sponges and
number of different sizes should be kept to a minimum. To
count them, the scrub person will do the following:
1. Hold the entire pack of sponges of whatever type,
including tapes, in one hand. The thumb should be over the
edges of the folded sponges.
2. Break the paper band. Breaking the band is a good way to
designate which stacks have been counted and which ones
have not.
3. Shake the pack gently to separate the sponges and loosen
the twill-tape tails on tapes.
4. Pick each sponge separately from the pack with the other
hand, and number it aloud while placing it in a pile on the
sterile instrument table.
If a pack contains an incorrect number of sponges, the scrub
person should hand the entire pack to the circulating nurse for
removal from the room. There should be no attempt to correct
errors or to compensate for discrepancies. The pack should be
removed from the room and not used.

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 What can the scrub person do to ensure that a sponge is not
misplaced or left in the patient?

• Keep sponges, tapes, peanuts, and other such materials

separated on the instrument table and far away from each
other and from any draping material, especially towels.
• Keep sponges far away from small items (e.g., needles,
hemostatic clips) that might be dragged into the wound be a
sponge or tape.
• Do not give the surgeon or assistant a sponge to wipe the
powder off his or her gloves. It may end up in the laundry
hamper or trash. Use a sterile towel instead, if at all possible.
• Do not cut sponges or tapes. It may be hard to account for the
item in its entirety.
• Do not remove radiopaque thread or marker. Either the
marker or the sponge could be lost.
• Never mix sponges and tapes in a solution basin at the same
time; this prevents the danger of dragging a small sponge
unknowingly into the wound along with a tape.
• Do not give the pathologist a specimen on a sponge to take
from the room; instead, put the specimen in a basin or on a
towel.
• Discard all soiled sponges into the “kick bucket” after
completely opening them and leave no more than two clean
sponges on the sterile field at a time. Put up clean ones before

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 removing soiled ones on an exchange basis as part of a systems
approach to error prevention.
• Do not be wasteful of sponges. Besides the economy factor,
the more sponges that are used, the more there are to count -
and the greater the chance for error.
• Once the peritoneum is opened or the incision is made and
extends deep into a body cavity (where a sponge could be lost),
four alternative precautions can be taken:
a. Remove all Raytec sponges from the field, and use only
tapes. Rings, if used, hang outside, over the edges of the
wound.
b. Use folded Raytec sponges on sponge forceps only.
Completely unfold and open each one before dropping into
the sponge bucket.
c. Give laparotomy sponges to the surgeon one-at-a-time on
an exchange basis.
d. Dissectors are given one at a time clamped inside the tip of
an instrument on an exchange basis.
e. With the circulating nurse, count sponges and tapes added
during the surgical procedure before moistening or using
them. Break the paper band to signify they have been
counted.
f. Do not add or remove sponges from the surgical field
during a sponge count until the count is verified as complete
and correct. Before hanging the final count, place one or two

33
 tapes or sponges on the field for use while the count is being
taken.

What can the circulating nurse do to ensure that a sponge is

not misplaced or left in a patient?
1. Each discarded sponge should be examined briefly to be sure
that no saturated sponges are tangled with them. To avoid the
transmission of bloodborne pathogenic organisms, wear gloves
and protective eyewear to separate sponges for counting,
stacking, and bagging.
2. Count the bagged sponges in the same increment in which they
are supplied, such as groups of 5 or 10 of like sponges. These
numbers should be recorded on the sponge count record and
counted. The bagged units are not tied shut or discarded into
the trash. The bags are placed aside in full view of the scrub
person and the anesthesia provider until the end of the case
and all the numbers are reconciled. The anesthesia provider
will be observing the sponges for loss of blood.
3. Give additional sponges or tapes to the scrub person when it is
convenient for them. The scrub person separates each sponge
and counts them, and the circulating nurse records the
numbers immediately.
4. Do not discard or remove counted sponges from the room for
any reason until the patient is out of the room.

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 Sharps include surgical needles, hypodermic needles, knife
blades, electrosurgical needles and blades and safety pins, to
mention a few. Each item must be accounted for. Surgical
needles are the most difficult to track, and are used in the
largest quantity. All surgical needles and other sharps are
counted as they are added to the sterile table and/or separated
from other instruments in the instrument tray.
What can the scrub person do to ensure that a sharp is not
misplaced or left in a patient?
1. Leave needles in their inner folder or dispenser packet until the
surgeon is ready to use them.
2. Give needles to the surgeon on an exchange basis.
3. Use needles and needle holders as a unit. No needle on the
Mayo without a needle holder, and no needle holder without a
needle.
4. Secure used needles and sharps in a needle counting box until
after the final count. Many methods for efficient handling are
available:
a. Sterile adhesive pads with or without magnets facilitate
counting and safe disposal. When a large number of swaged
needles will be used, the scrub person and circulating nurse
may determine the number of needles a pad will hold and
work out a unit system. When this maximum number is
reached and counted by both, the pad or box is closed and

35
 handed off to the gloved circulating nurse, who will place the
container with the other countable items off the field. This
method eliminates the hazard of handling extreme amounts
of loose needles on the instrument table. Disposable plastic
boxes of various sizes for the containment of sharps are
commercially available.
b. Used eyed needles can be returned to the needle rack.
The use of reusable suture needles is not encouraged because
they become dulled with use and could harbor
microorganisms if not properly cleaned.

How can the circulating nurse ensure that a sharp is not

misplaced or left in a patient?
1. Open only the necessary number of packets of sutures with
swaged needles. Overstocking the instrument table is not only
wasteful, but also complicated the needle count.
2. Counted sharps should not be taken from the OR during the
surgical procedure. If a scalpel with a counted knife blade is
given to a pathologist to open a specimen, the scalpel must
remain in the room after gross examination of the specimen; it
is not to be taken to the laboratory with the specimen.
3. A sharp is passed off the sterile field if it punctures, cuts, or
tears the glove of a sterile team member. These sharps are
retained and added to the table and field counts to reconcile

36
 the final sharp count. An empty specimen cup is generally
regarded as good container for a loose sharp.
4. A magnetic roller may be used to locate a surgical needle or
blade that has dropped to the floor.
Instruments are surgical tools and devices that are designed to
perform specific functions that include cutting or dissecting,
grasping and holding, clamping and occluding, exposing, or
suturing. For each basic maneuver, an instrument of suitable
size, shape, strength, and function is needled.
Just like sponges and sharps, instrument counts are
recommended for all surgical procedures. Specific written
policies and procedures are followed without deviation. To
count instruments, the scrub person should do the following:
1. Remove the top rack of instruments from the instrument tray
or container and place it on a rolled towel or over the lip of a
tray or container. Instruments are counted as they are
assembled in standardized sets. Groups of even numbers of
each of the basic clamps facilitate handling and counting.
2. Expose all instruments left in the tray for counting. Remove
knife handles, towel clips, tissue forceps, and other small
instruments from the tray, and place them on the instrument
table. Do not put instruments on the Mayo stand until they are
counted; they can be put on the stand as they are being
counted.

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3. Account for all detachable and disassembled parts. These must
be counted or accounted for during assembly and once again
during disassembly at the end of the case.
4. Recover and retain all pieces of an instrument that breaks
during use. A replacement instrument is added to the count
sheet.
5. After the initial count is taken, count any instruments added to
the table, with one exception. If the circulating nurse
decontaminated and sterilizes an instrument that has been
dropped to the floor or has been passed off the table, an
adjustment in the count is unnecessary. Instruments that are
recovered from the floor or passed off the table and not
sterilized are retained by the circulating nurse and reconciled at
the closing count.

As operating room personnel, we all have our story of the “near

miss” related to counting. Any item put into the patient should
be documented as part of the count and reconciled at the end
of the procedure to avoid any “near misses”. Because
accountability for sponges, sharps, and instruments is essential
to the safe practice and the standard of care, the scrubbed
personnel and the circulating nurse have a huge responsibility.
There is no excuse for any retained foreign object if the systems
for accountability are followed by the entire team. I hope that

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 this course increases your awareness of the importance of
counting to a safe operating room experience, and how vital
the circulating nurse is to a safe surgical experience.

• \

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 References

1. ACORN. (2003). Counting of Accountable Items. Standards,

Guidelines and Policy Statements. (reference:A6;pp.1-5)
2. Alexander’s Care of the Patient in Surgery, 2011
3. American College of Surgeons. (2005, October). Statements on
the prevention of retained foreign bodies after surgery.
Bulletin of the American College of Surgeons, 90(10).
4. AORN. (2007), Recommended practices for sponge, sharp, and
instrument counts. Standards, Recommended Practices and
Guidelines, 493.
5. Barrow CJ: Use of x-ray in the presence of an incorrect needle
count, AORN J 74(1):80-81, 2001
6. Berry & Kohn’s Operating Room Technique, 2007.
7. Berguer R, Heller PJ. Preventing sharp injuries in the operating
room. Jam Coll surg. 2004; 199-462-467
8. Murphy E K. Liability for waived or inaccurate instrument
counts. AORN journal July 12009;30:14-19
9. Patterson P: How Ors decide when to count instruments, OR
Manager 16(4):11-14, 2000
10. Recommended practices for sponge, sharp, and
instrument counts. In 1999 Standards, Recommended
Practices, and Guidelines. Denver:AORN, 1999

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11. Reeder JM: Being there: Supporting health professionals
involved in medical errors, SSM 7(5):40-41,43-44,2001
12. Voss SJ: Creating a safety culture, SSM 7(5):6, 8-9, 2001
13. Surgical objects accidentally left inside about 1,500
patients in U.S. each year. (2007, December 9). Science Daily.

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