The Newcastle upon Tyne Hospitals NHS Foundation Trust

Count Procedure

Version No.: 4.0

Effective From: 07 December 2017
Expiry Date: 07 December 2020
Date Ratified: 15 November 2017
Ratified By: Theatre Users Groups

1 Introduction

The overriding objective for the count is that all mops/swabs packs, instruments,
single use items and sharps must be accounted for at all times during an invasive
surgical procedure, to prevent foreign body retention and subsequent injury to the
patient.

Retained objects are considered a preventable occurrence and careful counting and
documentation can significantly reduce, if not eliminate these incidents also known
as one of the “Never Events”. A Never Event was described as serious, largely
preventable patient safety incidents that should not occur if the available
preventative measures have been implemented. A count must be undertaken for all
procedures in which swabs, instruments and sharps could be retained.

It is accepted that some surgical procedures carry a greater risk than others, for
example there is a higher risk of retaining swabs and surgical instruments during
abdominal and thoracic surgery than there is during ophthalmology surgery.

2 Scope

The scope of this policy is to provide evidence based guidance to all healthcare
professionals when they are required to account for all mops/swabs, packs
instruments, extras and sharps used during an invasive surgical procedure, to
prevent foreign body retention and subsequent injury to the patient.

3 Aims

The aim of this policy is to standardise the procedure for accounting for all
mops/swabs and instruments used during operative procedures. This policy is of
primary interest to all Theatre Nursing, Non-Nursing Staff and Operating Department
Practitioners when performing count activities.

4 Duties (Roles and responsibilities)

 The Executive Team is accountable to the Trust Board for ensuring Trust-
wide compliance with policy.
 Directorate managers and heads of service are responsible to the
Executive Team for ensuring policy implementation.
 Managers are responsible for ensuring policy implementation and
compliance in their area(s).
 All staff are responsible for complying with policy.

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5 Definitions
ANTT Aseptic Non Touch Technique
DSC Delayed Sternal Closure
HDU High Dependency Unit
ITU Intensive Therapy Unit
SSD Sterile Services Department
TMO Training Manager on Line
WHO World Health Organisation

6 Count Competence

An introduction to the Count Policy must be included in all new Operating Theatre
staff’s Induction programme. Both registered and non-registered staff must
successfully complete the Count Competency and documentary evidence should be
available.

Pre-registered nursing students and student ODP’s must have supernumerary status
until they have been deemed competent to assist with the count by an appropriately
qualified member of the scrub team. It is recommended that this should be the
designated registered student assessor / mentor and done under direct supervision
and countersigned.

6.2 Disposable Items

A count must be performed prior to all operations and all items added to the
dry wipe count board however minor. Countable items may include but are
not limited to the following items:-

 Mops/Swabs/Packs
 Red swab ties / pack ties
 Pledgets / patties
 Blades
 Atraumatics
 Diathermy Tip Cleaners
 Bert Bags (Laparoscopic Retrieval Bag)
 Needles
 Vessel / Nerve Loops
 Screws
 Any other specials

However, Ophthalmology is excluded from counting swabs in certain cases

(List monitored by Ophthalmology Theatre Sister).

6.3 Instrument Count

An instrument count will include the following:

 All tray instruments
 All supplementary instruments
 All single use instruments

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 The “FULL” count is therefore divided between disposable items
(mops/swabs, packs needles etc.) and instruments (including single use
instruments).

Tray lists must be available to provide an accurate record of instruments. The

list must be used to check the instruments prior to the start of surgery and
again on completion of the surgery and if scrub/count personnel change over
during procedure.

Tray list must be held by the count practitioner and each item on the list read
out loud and marked off individually when seen.

There must be a local traceability system of all instruments used during the
procedure.

Theatre staff will keep a record of all instrument trays used on individual
patients by recording them in the Tray Tracking / Surgi Net system.

Supplementary instruments will be entered into the appropriate theatre record

book along with the SSD label and patient details. Supplementary instruments
will, in future be supplied by SSD with a T-Doc bar-code. These can be
recorded in the Tray Tracking / SurgiNet System.

Supplementary instruments should be added to the additional spaces at the

bottom of the count sheet to be included in the count.

Ideally, the count person will be the only member of staff to provide the scrub
practitioner with additional instruments.

Instruments and items with screws and or removable parts must also be
included in the count at the beginning and end of the procedure.

The integrity of the instruments must be checked at the beginning and end of
the procedure.

6.4 Atraumatics

All atraumatic suture packets must be retained until the final count is
completed.

 Opening all suture packages during the initial needle count is not
recommended.
 Used needles on the sterile field must be retained in a
disposable, puncture resistant needle container.

6.5 Digital Tourniquets (Hands and Feet)

Tourniquets are commonly used to provide a bloodless field in hand and toe
surgery and when a digital tourniquet is opened this must be recorded as part
of the Count Procedure.

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 Documentation of the removal of digital tourniquets is required as part of the
Count. Procedure and must include the length of time a tourniquet is in place
(i.e. time on and time off). This must be recorded upon the WHO check list
and Surginet system.

CE marked digital tourniquets that are labelled and/or brightly coloured should
be used in accordance with manufacturer’s instructions.

Surgical gloves MUST not be used as tourniquets.

6.6 Count Procedure

Prior to the commencement of the surgical procedure, the scrub and count
practitioners will perform the count together. This count is conducted audibly
i.e. both practitioners must count aloud and in unison.

Each count must be performed by two members of staff, one of whom must
be a count competent practitioner. The staff involved in the counting
procedure must be able to recognise and identify the “Instruments /
disposables” in use, and the same two personnel should perform all the
counts that are done during the surgical procedure.

The surgical team must allow time for these counts to be undertaken without
pressure. This should be done in a quiet and controlled environment with
reduced noise and no interruptions. As with time out, the Scrub and Count
staff should take time out to prepare for the formal count procedure to take
place.

All music must be turned off and background theatre noise minimised to
enable the count to be performed correctly. If any interruption occurs, the
count should be resumed at the end of the last recorded item.

Trust standard pre-printed Count Sheets must be used to record all

disposable items see (Appendix 1).

Provision must be made in the theatre for a dry wipe count board, which is
permanently fixed to the theatre wall. This should be at an appropriate height
and in a position that facilitates easy access and visibility during the
procedure.

All disposable items will be recorded on the count sheet and on the count
board, so that the scrub practitioner can monitor any additional swabs etc.,
throughout the procedure. When additional items are added, they must be
counted at the time and recorded as part of the documentation to keep the
count accurate and current.
At all times during a surgical procedure, the scrub practitioner must be aware
of the location of all swabs, instruments and medical devices. Neatness in
approach must be encouraged to ensure that only necessary equipment is in
use at any time.

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 A standardised layout for instrument trays must be locally agreed to aid a
smooth transition between scrub practitioners should a change over count is
necessary.

Any mops/swabs packs or any other items placed inside the patient and
therefore out of sight must be recorded on the dry wipe count board.

Should it be necessary to replace either person during the procedure, a

complete count must be performed, recorded and signed by the incoming and
outgoing practitioners on the intraoperative record and Surginet.

The initial full mop/swab and instrument count must be performed immediately
prior to the commencement of surgery. A second count must take place
before closure of a cavity within a cavity, before wound closure begins, and
finally at skin closure or end of procedure.

In the event of a NCEPOD 1 immediate life threatening emergency, it is

recognised that it is not always feasible to perform an initial full swab and
instrument count. In these circumstances all packaging must be retained to
facilitate a count being undertaken at the earliest opportunity.

If a scrub practitioner is not required for the procedure (such as dilatation and
curettage), the Circulating Practitioner should be a count competent with
whom the operating surgeon must perform the count.

Any discrepancies must be reported to the surgeon at the earliest opportunity

and a verbal acknowledgement must be received. (Refer to ‘Procedure to be
followed if a Count is found to be Incorrect’).

All documentation must be signed by both the scrub practitioner and the count
practitioner; the surgeon must also sign to state that they have been informed
the count is correct.

A full handover from the Scrub and Anaesthetic Practitioner must be given to
the Recovery / Ward / Critical Care practitioners.

6.7 The Procedure for Counting Swabs

The term “swabs” includes all x-ray detectable gauze products including mops
swabs, packs, peanuts, pledgets, patties etc. All swab ties must be retained
until the final count is completed

 It is the designated Count Practitioners’ responsibility to keep the scrub

practitioner supplied with additional mops/swabs pack, and other
disposable item. The count practitioner will ensure that nothing is removed
from the theatre without the permission of the scrub practitioner, e.g.
specimens.
 The integrity mops/swabs /packs and x-ray detectable markers must be
checked during the count, including attached tapes.

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  Mops/swabs and packs must be carefully segregated throughout the
procedure to prevent miss counts.
 During the procedure, mops/swabs must be counted into separate groups
of five only. These must not be added to those already counted until
verification of the number in the packet; however on some occasions (for
example patties are supplied in packs of 10) items may be counted in
groups of 10 any additions must be in multiples of five / ten (patties).
 In the event of an incorrect number of mops/swabs (i.e. not five), the entire
packet must be removed from the procedure area. The batch and Lot
numbers must be identified and the appropriate suppliers notified as
required.
 All used mops/swabs must be fully opened and placed into the individual
pockets of the count bags with an opaque backing. When ten mops/swabs
have been bagged and counted the count bag is then rolled up secured
and clearly labelled as 10 mops/swabs. They are then stored in clear view
of the scrub practitioner.
 Packs must be fully opened and the tape checked. When 5 have been
bagged and counted the count bag is then rolled up secured and clearly
labelled and kept in clear view of the scrub practitioner.
 The Scrub and Count Practitioners’ will count any additional disposable
items together. These will be added to the count sheet then to the count
board.
 If a counted item is inadvertently dropped off the sterile field, the circulating
practitioner must retrieve it, show it to the scrub practitioner and place it in
the appropriate location to be included in the final count.
 In all procedural counts, the Scrub and Count Practitioners will count the
bagged mops/swabs first those:
1. Hanging in the count bags
2. Any remaining swabs on the instrument trolley
3. Or in the sterile field.
 On completion of the final count, a verbal statement must be made to the
surgeon by the scrub practitioner to the effect that the final count is
completed and correct and all items accounted for.

A verbal acknowledgement must be received from the surgeon to alleviate

any misunderstanding.

6.8 Counts during surgical procedures

As there are many different procedures/operations undertaken in the theatres

across the trust, a specific number of counts could not be given but:-

 A count must be completed before closure of any internal organs or

cavities and the surgeon is notified that this is correct.
 All procedure counts are conducted in the same order as the pre-operative
count; commencing with the discarded unsterile mops/swabs/packs
followed by those remaining in the sterile field.
 The first count of all items will be conducted at the start of the first layer
closure and the surgeon is notified that it is correct.

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  On completion of each count a verbal statement by the scrub practitioner,
to the effect that the disposable count is correct must be made to the
surgeon.
 Verbal acknowledgement must be received from the surgeon to alleviate
any misunderstanding.
 In some cases, it may be necessary to perform additional counts during
closure. The scrub practitioner can do as many counts as they deem
necessary to ensure they know where all swabs instruments and sharps
are through out the procedure.
 The count must be conducted at the start of the skin closure and the
surgeon is notified that it is correct. It is important to remember that it may
not be the Consultant who has carried out the procedure although he may
be present in a supervisory capacity. The surgeon closing the wound has
been informed and acknowledged that the final count is correct.
 A definitive post-surgery count must be done when the dressing is
applied and all surgical contact with the patient has ceased but prior to
reversal of anaesthesia and the patient leaving theatre.
 All remaining loose mops/swabs and packs should be placed in count
bags prior to this count to ensure they are disposed of in multiples of five
or ten
 The scrub practitioner must confirm that they are in receipt of all counted
items to the surgeon.
 Items which are to remain in the patient by intention, (e.g. drainage tubes,
catheters), must be recorded on the intra-operative electronic record and
patients notes.
 If any countable item are deliberately left inside a patient (e.g. packing
gauze, raytec roll). This must be recorded in the electronic intra-operative
record / patient’s notes and theatre register. Recording must include
date and time. (See section 6.9.2)
 Its removal must also be recorded in the intra-operative electronic record,
patient notes and theatre register.
 WHO SIGN OUT: this must be read out loud ensuring all staff present are
participating and responding to their particular section of the questions.
 When this has been completed and on the scrub practitioners request, all
mops/swabs/packs can then be disposed of by placing into a clinical waste
bag swan necked and cable tied and clearly labelled
 When a sharps count is complete, all sharps must be placed on the sharps
pad, the sharps pad closed securely and then disposed of into the sharps
bin by the scrub practitioner.

6.9 Procedure to be followed if a Count is found to be Incorrect

(Whether, unintentionally incorrect or intentionally incorrect).

6.9.1 Unintentionally Incorrect

 No mops/swabs, packs or instrument should be left unless this has
been deemed to be intentional.
 If, at any stage in the operation, there is a discrepancy in the count,
the surgeon must be notified immediately and informed specifically

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 of what item / items are missing so that he can stop closure and re-
check the wound.
 The Team Leader in charge of theatre must be notified immediately.
 A thorough search of the operating room must be conducted.
 If the discrepancy remains, x-rays may be ordered by the surgeon
to ensure that the missing item is not in the wound prior to the
patient leaving the theatre.
 Image intensifier should not be used as they may fail to locate radio
opaque swabs.
 All missing items must be documented on the count form and in the
electronic operation record and signed as incorrect by the surgeon,
the scrub practitioner and the count practitioner.
 The scrub practitioner must then ensure the count form is filed
within the patient’s notes.
 The scrub practitioner must complete a Datix incident form.
 The Matron for theatres must be informed as soon as possible.

6.9.2 Intentionally Incorrect

On occasions, it is accepted that surgeons will intentionally leave
swabs, packs, or any other item included in the count inside the patient
with the intention of removing the item or items in the future.

When this occurs the following procedure must be followed;

 For cardiac procedures where items have been intentionally left in

the chest or the sternum has not been closed, the Delayed Sternal
Closure Pathway documentation must be complete and the
appropriate appendix for each following encounter. The document
must be retained in a yellow folder in the patient’s notes and
accompany the patient at all times until the item has been removed
and the chest / sternum fully closed.
 The scrub practitioner must verbally confirm with the surgeon
specifically what item / items have been retained in the patient.
 All items that have been intentionally left inside the patient must
be clearly documented in the patient records (usually the Operation
Record), the count form and WHO Check List or in Guideline for
carrying out the Cardiothoracic Delayed Sternal Closure document.
Clearly stating the type/size and amount of mops/swab/packs
and location of any intentionally retained to facilitate the safe
removal at the next surgical intervention and clearly stating the date
for removal of the swab/pack if this is to be removed on the ward as
part of the patient’s post-operative care.
 To ensure the safe removal of any intentionally retained
mops/swabs/pack items particularly those to be removed on the
ward during the immediate post-operative period, clear
instructions must be recorded on the back of the surgeon’s
operation record and patient records. Recovery Staff must also
ensure that this information is provided during the handover to the
ward staff when returning patients back to the ward or Critical Care.

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  The scrub practitioner must also document any discrepancy within
the operating theatre register.
 It is further recommended that both the surgeon and the scrub
practitioner check this documentation prior to any subsequent
surgery for removal of the item / items.

6.10 Procedure to be followed for Multi-disciplinary Surgical Procedures

This advice is supplementary to that laid down in the Policy Statement for
Count Procedure and is applicable to all procedures where a change of
surgeons takes place and/or more than one surgeon is operating at the same
time on different operation sites.

Prior to commencement, a decision must be made by the theatre team as to

whether a single count is undertaken or separate (tandem) counts
undertaken.

6.10.1 Single Count Procedure

Use count procedure.

6.10.2 Tandem Count Procedure


The theatre Team Leader will be responsible for identifying the
roles of all the other theatre staff involved i.e. scrub practitioner(s),
count practitioner(s) etc.
 A ‘counting’ team of four staff will be used, made up of two scrub
practitioners and two count practitioners. Two separate teams each
consisting of a scrub and count practitioner, will participate in the
count of both instruments and disposable items as outlined in the
Trust policy (in some circumstances a single count person may
undertake the role for both Scrub Practitioners).
 Separate count sheets must be used for each Count.
 The count practitioner for each of the scrub practitioners will be
responsible for ensuring that all equipment used for their procedure
is separately identified at all times during the procedure.
 Ideally there will be two white boards situated at opposite ends of
theatre and clearly visible to the scrub practitioners. Mops/Swabs
etc. from each count must be kept apart at a safe distance.
 If one count is completed before the joint procedure is finished, any
trays used must be loosely wrapped and left to one side (they must
NOT be removed from Theatre). All countable items must be
bagged and retained in the theatre until such time as both counts
are known to be correct.
6.11 Procedure for Checking Sterility of Instrument Trays, Tins, Caskets and
Containers

The following procedure must be undertaken for checking sterility prior to

surgical intervention using the instrument tray system.

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 All sterile trays, tins/caskets and extras for use during surgical procedures
must be fully checked before opened to avoid any contamination of the sterile
field.

6.11.1 Preparation
All members of Scrub/Circulating Theatre staff must have been trained
in the safe checking and opening of sterile trays, tins/caskets and
extras.

They must be approved as competent by their clinical mentor before

undertaking this as part of their routine clinical practice activities.

6.11.2 Checks to be performed before opening

 Circulating Practitioners must check and ensure that the trays,
tins/caskets or extras to be opened are intact e.g. no visible tearing
of either outer drape or external wrapping or visible signs of
contamination.

 Discard any trays, tins/caskets or extras that the packaging that

contains any moisture as it is not fit for purpose.

 All Trays, tins/caskets should be cooled and dry before they are
released from the SSD department.

 All sterile trays from the SSD department have an expiry date on
the tray information label. Staff must be aware that all packaging
has a shelf life and must therefore examine each item before
opening to check the expiry date has not been exceeded.

 Some disposable purchased pre-sterilised items are sterilised using

irradiation it is important to note that these items carry an expiry
date, which must be checked before opening.

 Any tray, tin/casket or package that has auto-clave tape on the

outer packaging must be checked to ensure that the tape colour has
changed from pink to brown indicating that the item has been
through a correct autoclaving process and is deemed to be sterile.

 When an item is packaged in a bag, staff must keep it in an upright

position and present the inner package to the scrub practitioner or
decant into a designated safe zone e.g. sterile bowl.

6.11.3 Opening Trays

 Circulating Practitioners – Ensure the trolley is clean and dry
before placing the trays ready to open.

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  All auto-clave tape must be peeled upwards and care being taken
not to tear the outer packaging when opening tray and the binders
are carefully removed.

 Trays must be opened in a manner whereby the Circulating

Practitioner does not lean over and contaminate any part of the
sterile inner drapes.

 The Circulating Practitioner will peel back the back flap of the tray
to open then the two side flaps leaving the front flap until last to
minimise the risk of contamination of the tray.

6.11.4 Scrub Practitioners

 Expiry date has not passed.

 Autoclave tape has changed to brown indicating the sterilisation

process has been completed.

 The Scrub practitioner will open the front flap of the tray first, then
open the two side drapes and lastly peel back the posterior flap
when open in a sterile tray to minimise the risk of contamination and
maintain the sterile field.
 The scrub practitioner must check that the date on the tray list has
not expired and that the sterility indicator label has changed from
pink to brown indicating that the sterilisation process is complete. If
the tray is accepted, the label is peeled off and placed in the
patients’ record by the person undertaking the count following the
initial instrument count.

 If the date has expired or the indicator label has not changed colour,
the instruments must not be used and the tray must be returned to
SSD for re-processing.

 Items must be presented to the scrub person from the designated

edge of the sterile field.

 A clearly dedicated location must be identified for decanting sterile

items and extras when setting up the sterile field e.g. sterile bowl.

 Items must not be dropped onto the scrub trolley without the scrub
persons consent and knowledge of the item first.

 Sutures must be peeled open and presented for the scrub person to
take.
 Staplers and disposable pre-packaged items should have the paper
peeled back and be presented for the scrub practitioner to lift out of
the packaging.

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 6.11.5 Opening of Tins/ Caskets
Circulating Practitioners – Ensure the trolley is clean and dry before
placing the tin/container ready to open as the person responsible for
setting up for the case will select instrument trays according to
surgeons’ preference card. Each tray must be examined to ensure the
following:

The following checks of the outside of the Tins/ Caskets should be

performed:

 Tray wrap integrity has not been breached (no tears or holes
in wrap)
 Check all of the details on the information label
 Check the expiry date
 Check the steam indicator has changed from Pink to Brown
 Check the SSD tape has change to brown
 Check that the Tray binding is intact and secure
 Check the autoclave batch number and packer information is
displayed
 Check the plastic D Ring is complete and intact

The person responsible for opening the outer wrap ready for use by the
scrub practitioner will undertake a second check as outlined above
before opening the tray.

If any of the above are incorrect at either check, the tray must be
returned to Sterile Services Department for re-wrap / re-processing and
a new tray selected that conforms to all of the above requirements.

Checks when open

 Final Check that indicator label inside the tray has changed colour if
it is still PINK DO NOT USE! As the steam has not penetrated the
pack and the set will not be sterile

6.11.6 Deviation from Procedure

An incident report must be completed if there is any deviation from the
above procedures as a near miss occurrence.

6.12 Procedure for Missing Instruments in Sterile Services Department

6.12.1 Aim
To ensure that the instrument has not been retained in a patient.
Of Primary Interest to SSD and Operating Theatre Personnel.

The following action must be taken when a Sterile Services Department

operative identifies an instrument tray as incomplete.

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 This procedure must be followed at the earliest opportunity.

6.12.2 Procedure
 Report the discrepancy to the appropriate speciality theatre Sister
or designated deputy.
 Do not pack the instrument tray.
 Completion of notification form by SSD supervisor and theatre
Sister or designated deputy. (Appendix 2)

SSD staff should complete their section and then send the form to the
Sister in charge of the speciality to enable them to complete it and
record any action taken.

Theatre Sister or designated deputy must assess / undertake the

following:
 Could instrument be in the patient?
 Search linen / rubbish.
 Check Count Sheets.
 Discuss with scrub / count staff involved.
 Discuss with surgeon.
 Discuss with SSD Supervisor.

6.12.3 Instrument not found:

 Incident form (Datix) must be completed by scrub practitioner,
highlighting action taken.
 A copy of “reporting form” must be attached to incident form.
 Theatre Sister must keep an additional copy of “reporting form”

6.12.4 Replacement of lost instrument

 Theatre Sister should inform SSD that the tray can be processed
and reused.
 If a replacement instrument is not immediately available the tray list
must clearly identify the discrepancy.
 Theatre is responsible for purchase of a replacement instrument.
 Theatre is responsible for ensuring replacement instrument is
returned to SSD informing them of the tray name and number to
ensure instrument is replaced onto the correct tray.
 Theatre Sisters copy of “reporting form” must be completed and
filed for reference.

6.13 Procedure for Missing Instruments when trays are opened in Theatre

6.13.1 Aim
To ensure that an instrument has not been sent for repair or been taken
out of use whilst waiting for a replacement or that it has been found in
the Sterile Services Department

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 Of Primary Interest to SSD and Operating Theatre Personnel.
The following action must be taken when a member of theatre staff
identifies an instrument tray as incomplete. This procedure must be
followed at the earliest opportunity.

6.13.2 Procedure
 Check repair service database to ascertain whether or not
instrument has been sent for repair.
 Report the discrepancy to a Sterile Services Department
Supervisor.
 Completion of a notification form by member of theatre staff that
identified the discrepancy (Appendix 3.)
Theatre staff will complete their section and then send the notification
form to the Sterile Services Department manager / deputy to enable
them to complete it and record any action taken.

6.13.3 SSD Staff must assess / undertake the following:

 Search of the wash area.
 Search of the packing area.
 Discuss with the tray signatory.
 Discuss with the tray check signatory.

6.13.4 Instrument found:

 Contact theatre staff identified on the report sheet or Sister in
charge of the speciality to inform them of the outcome e.g.
instrument is away for repair / awaiting replacement or has been
found in SSD.
 Instrument identified, reprocessed and set aside in the packing
room with details of the tray on which it is to be replaced when
returned from theatre.

6.13.5 Instrument not found:

 Incident form (Datix) must be completed by SSD Supervisor,
highlighting action taken. A copy of “reporting form” must be
attached to incident form.
 SSD Supervisor must keep an additional copy of “reporting form”
(See Appendix 2)
 If a replacement instrument is not immediately available the tray list
must clearly identify the discrepancy.
 SSD/Instrument Curator will be responsible for purchase of a
replacement instrument.
 The instrument Curator is responsible for ensuring replacement
instrument is returned to SSD informing them of the tray name and
number to ensure instrument is replaced onto the correct tray.
 Supervisors’ copy of “reporting form” must be completed and filed
for reference.

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7 Training

In order to achieve competence in these procedures the practitioner must have

completed the Count Competency training and has been deemed competent.
Competence must be documented using the Trust standard documentation.

8 Equality and Diversity

The Trust is committed to ensuring that, as far as is reasonably practicable, the way
we provide services to the public and the way we treat our staff reflects their
individual needs and does not discriminate against individuals or groups on any
grounds. This document has been appropriately assessed.

9 Monitoring Compliance

Monitoring Compliance with this policy will be monitored by the Theatre Matrons
supported by the speciality Sisters / Charge Nurses and reported to the Directorate
Manager who from analysis of incident reports relating to an incorrect count will
provide a report to the Clinical Governance and Quality Committee.

Standard / process Monitoring and audit

/ issue Method By Committee Frequency
All Scrub and count Audit Theatre Matrons and At least
Practitioners are sisters Clinical annually
competent as per Educators
this policy
ANTT is undertaken Audit Infection IPCC At least
as per this policy control nurses annually
No swabs, Serious Departmental Theatre User Continuous
instruments or Incident Heads Group
needles are Review of
unintentionally incident
retained reports
(Datix)
All intentionally Datix Departmental Theatre User Continuous
retained swabs, Incident Heads Group
instruments or Reporting &
needles follow the Review
intentionally retained Audit Theatre Theatre User At least
procedure Sisters Group annually
Digital Tourniquets Audit Theatre Theatre User At least
are used as per Sisters Group annually
policy
Count Procedure is Audit Theatre Theatre User As a
undertaken as per Sisters Group minimum
policy Annually
W.H.O. checklist is Audit Theatre Theatre User As a
completed as per Sisters Group minimum
policy Annually

Page 15 of 38
 Tandem Procedures Audit Theatre Theatre User As a
are carried out as per Sisters Group minimum
policy Annually
Sterility of Trays and Audit Theatre Theatre User As a
containers are Sisters Group minimum
checked and Annually
maintained as per
the policy
Any deviations from Datix Report Theatre Theatre User Continuous
procedure are Matron Group
reported and
reviewed as per
policy.
Missing Instruments Review Datix Theatre Theatre User Continuous
are followed up as Report Matron Group
per the policy
Audit Theatre Sister Theatre User At least
Group annually

10 Consultation and review

This policy has been reviewed in consultation with the Theatre User Group,
Perioperative Matrons and Clinical Educators and will be reviewed on a 3 yearly
basis, unless evidence is presented that requires review sooner.

11 Implementation (including raising awareness)

This policy is a revision of a previous Count Policy; this revised policy will be
introduced and awareness raised through the Theatre User Group, Directorate
Communication meetings, senior staff and Departmental staff meetings.

12 References
 Association for Perioperative Practice, (2011). Standards and
Recommendations for safe perioperative practice.3rd ed. Harrogate: AFPP
 Hughey M. (2008). Scrub Gown and Glove Procedures [online]
www.brooksidepress.org]

13 Associated Documentation

 Delayed Sternal Closure Pathway

 Hand Hygiene Policy

 Infection Control in the Operating Theatre
 Mandatory Training Policy
 Waste Management Policy

Page 16 of 38
Trust Theatre Count Sheets Appendix 1
The Newcastle upon Tyne Hospitals NHS
NHS Foundation Trust
PERI OPERATIVE THEATRES COUNT SHEET: CENTRAL OPERATING THEATRES Example Only
Hospital FH Surname MRN Number
Theatre
Forename D.O.B.
Date
Surgical Count this is a record of the number of, variety of swabs and
Address NHS No
instruments used within the perioperative fields etc., during the operation
performed on the above named patient. Sex Male/ Female

Items
Mops 10 x 10

Packs 30 x30

Packs 45 x 45

Pledgets
Stamps
Tonsil Mops
Nasal Tampons

Blades
Atraumatics

Needles
Tapes
Reels
Loops
Suture Boots
Diathermy Tips
Tip Cleaner
Screws
Bulldogs
Tibbs

Saw Blades

INTENTIONALLY RETAINED GAUZE

Type………………………………………………………
Amount…………………………………………………………..

Surgeon closing the wound has been Scrub Practitioner Print ……………………………………………..
informed that the count has been
completed and that the count is Scrub Practitioner Sign ……………………………………………..

Correct / incorrect (circle). Count Practitioner Print …………………………………………..

Surgeon Print Name ……………………………….. Count Practitioner Sign ……………………………………………….

Signature …………………………………………….. Change Over Count / Scrub Print…………………………………

Change Over Count / Scrub Sign……………………………………
Page 17 of 38
Tray Labels and Traceability Stickers

Page 18 of 38
 The Newcastle upon Tyne Hospitals NHS
NHS Foundation Trust
PERI OPERATIVE THEATRES COUNT SHEET: Cath Labs Cardio Example Only
Hospital FH Surname MRN Number
Theatre
Forename D.O.B.
Date
Surgical Count this is a record of the number of, variety of swabs and
Address NHS No
instruments used within the perioperative fields etc., during the operation
performed on the above named patient. Sex Male/ Female

Items Total
30x30
Packs
10x10
Swabs

Sponges

Blades

Atraumatics

Needles
Yellow Vein
Lifters
Diathermy Tip
Disposable
Clips

INTENTIONALLY RETAINED GAUZE

Type/ Size …………………………………………… Amount…………………………………………………….

Scrub Practitioner Print ……………………………………………..

Surgeon closing the wound has been Scrub Practitioner Sign … …………………………………………..
informed that the count has been Count Practitioner Print …………………………………………….
completed and that the count is Correct /
incorrect (circle). Count Practitioner Sign …………………………………………….

Surgeon Print Name ………………………………. Change Over Count / Scrub Print…………………………………

Change Over Count / Scrub Sign…………………………………

Page 19 of 38
Blood Loss Record

Tray Labels and Traceability Stickers

Page 20 of 38
 The Newcastle upon Tyne Hospitals NHS
NHS Foundation Trust
PERI OPERATIVE THEATRES COUNT SHEET: Cardio Theatres Example Only
Hospital FH Surname MRN Number
Theatre
Date Forename D.O.B.
Surgical Count this is a record of the number of, variety of swabs and
instruments used within the perioperative fields etc., during the operation Address NHS No
performed on the above named patient.
Sex Male/ Female

Items Total
30x30
Packs
10x10
Swabs/Child
15x2.5
Infant

Pledgets

Atraumatics

Blades

Needles
Filter
Needles

Tapes

Screws

Ligaclips
Diathermy
Tips

Tip Cleaner
INTENTIONALLY RETAINED GAUZE

Type/size………………………………………………… Amount
…………………………………………………………
Scrub Practitioner Print …………………………………………
Surgeon closing the wound has been
informed that the count has been completed Scrub Practitioner Sign………………………………………….
and that the count is Correct / incorrect
Count Practitioner Print ……………………………………….
(circle).
Count Practitioner Sign……………………………………………
Surgeon Print Name ……………………………….
Change Over Count / Scrub Print……………………………
Signature………………………………………………..
Page 21 of 38
Change Over Count / Scrub Sign…..…………………………
Items Total

Abbocath

Bulldogs

Red Slings

Arteriotomy

Shods
Silastic
Slings

Clamp
Inserts

Coreknots
Staple
Inserts
Microvascular
Clamps

Page 22 of 38
 The Newcastle upon Tyne Hospitals NHS
NHS Foundation Trust
PERI OPERATIVE THEATRES COUNT SHEET: OPHTHALMOLOGY THEATRES Example Only
Hospital RVI Surname MRN Number
Theatre
Date Forename D.O.B.

Surgical Count this is a record of the number of, variety of swabs and instruments Address NHS No
used within the perioperative fields etc., during the operation performed on the
above named patient.
Sex Male/ Female

Items
Mops 10x10

Mops 10x15

Packs 30x30

Pledgets

Cotton Buds

Dental Rolls

Neuro Patties

Spears

Blades

Atraumatics

Cannula

Needles

Iris Hooks

Ports

INTENTIONALLY RETAINED GAUZE

Type/ size…………………………………….. Amount……………………………………………….

Surgeon closing the wound has been Scrub Practitioner Print.…..…………….……………………….

informed that the count has been Scrub Practitioner Sign…..……………..……………………….
completed and that the count is Correct /
Count Practitioner Print ………………..………………………
incorrect (circle).
Count Practitioner Sign………………………………………..
Surgeon Print Name …………………….
Change Over Count / Scrub Print… ……………………….
Signature …………………………………….. Change Over Count / Scrub Sign……………………………

Page 23 of 38
Blood Loss Record

Tray Labels and Traceability Stickers

Page 24 of 38
 The Newcastle upon Tyne Hospitals NHS
NHS Foundation Trust
PERI OPERATIVE THEATRES COUNT SHEET: ORTHOPAEDIC THEATRES Example Only
Hospital RVI Surname MRN Number
Theatre
Date Forename D.O.B.
Surgical Count this is a record of the number of, variety of swabs and instruments
used within the perioperative fields etc., during the operation performed on the
Address NHS No
above named patient.

Sex Male/ Female

Items
Small Mops 10x15

Large Mops 36x11

Packs 45x45

Stamps/Pledgets

Blades

Atraumatics

Needles
Drill
K-wire
Guide wire
Saw blades
Burrs
Screws
Reels
Vessel loops
Tip cleaner

INTENTIONALLY RETAINED GAUZE

Type / Size……………………………………………… Amount…………………………………………….

Surgeon closing the wound has been Scrub Practitioner Print ……………………………………………….
informed that the count has been Scrub Practitioner Sign……………………………………………….
completed and that the count is Correct /
Count Practitioner Print ……..…………………………………….
incorrect (circle).
Count Practitioner Sign…………………………………………………
Surgeon Print Name ………………………
Change Over Count / Scrub Print… ………………………………..
Signature ……………………………………… Change Over Count / Scrub Sign……………………………………

Page 25 of 38
Blood Loss Record

Tray Labels and Traceability Stickers

Page 26 of 38
 The Newcastle upon Tyne HospitalsNHS
NHS Foundation Trust
PERI OPERATIVE THEATRES COUNT SHEET NEURO THEATRES Example Only
Hospital RVI / FH Surname MRN Number
Theatre
Date Forename D.O.B.

Surgical Count this is a record of the number of, variety of swabs and instruments Address NHS No
used within the perioperative fields etc., during the operation performed on the
above named patient.

Sex Male/ Female

Items
Mops 10x10

Large Mops 36x11

Packs 45x45

Pledgets
Tonsil/Mastoid swabs
Patties

Blades

Atraumatics

Micro vascular
Atraumatics

Needles
Screws
Tapes
Reels
Diathermy Tips
Sloops
Fish Hooks
Disposables
Red Ties
INTENTIONALLY RETAINED GAUZE

Type / Size………………………….... Amount………………………………………….

Surgeon closing the wound has been Scrub Practitioner Print ……………………………………………..
informed that the count has been Scrub Practitioner Sign……………………………………………..
completed and that the count is
Count Practitioner Print …………………………………………..
Correct /Incorrect (circle). Count Practitioner Sign…………………………………….………….
Surgeon Print Name …………………………………. Change Over Count / Scrub Print………………………..………
Signature …………………………………………………. Change Over Count / Scrub Sign ……………………………….…

Page 27 of 38
Blood Loss Record

Tray Labels and Traceability Stickers

Page 28 of 38
 The Newcastle upon Tyne Hospitals NHS
NHS Foundation Trust
PERI OPERATIVE THEATRES COUNT SHEET PLASTICS & CHILDRENS THEATRES Example Only

Hospital RVI / FH Surname MRN Number

Theatre
Date Forename D.O.B.

Surgical Count this is a record of the number of, variety of swabs and Address NHS No
instruments used within the perioperative fields etc., during the operation
performed on the above named patient. Sex Male/ Female

Items
Mops 15x10

Packs 45x45

Stamps
Pledgets
Tonsil/Mastoid swabs
Patties
Palate mops

Blades

Atraumatics

Microvascular
Atraumatics

Needles
Screws
Tapes
Diathermy tips
Sloops
Scratch Pads
Digital tourniquet

INTENTIONALLY RETAINED GAUZE

Type/ size……………………………. Amount………………………………….

Surgeon closing the wound has been Scrub Practitioner Print ……………………………………………..
informed that the count has been
completed and that the count is Scrub Practitioner sign..……………………………………………..
Count Practitioner Print……………………………………………..
Correct / incorrect (circle).
Count Practitioner Sign.…………………………………………….
Surgeon Print Name ………………………………. Change Over Count / Scrub Print………………………………….
Signature …………………………………………….. Change Over Count / Scrub Sign…………………………………..

Page 29 of 38
Blood Loss Record

Tray Labels and Traceability Stickers

Page 30 of 38
 The Newcastle upon Tyne Hospitals NHS
NHS Foundation Trust
PERI OPERATIVE THEATRES COUNT SHEET GENERAL SURGERY & GYNAE THEATRES Example Only

Hospital RVI / FH Surname MRN Number

Theatre
Forename D.O.B
Date
Surgical Count this is a record of the number of, variety of swabs and
Address NHS No
instruments used within the perioperative fields etc., during the operation
performed on the above named patient. Sex Male/ Female

Items
Mops 15X10

Packs 45X45

Stamps
Tonsil swabs
Netcell

Blades

Atraumatics

Needles
Diathermy tips
Sloops
Tapes
Screws
Bungs
Slings

INTENTIONALLY RETAINED GAUZE

Type/Size …………………………………………….. Amount…………………………………………………………

Surgeon closing the wound has been Scrub Practitioner Print ………………………………………………
informed that the count has been Scrub Practitioner Sign ……………………………………………….
completed and that the count is
Count Practitioner Print ………………………………………………
Correct / incorrect (circle). Count Practitioner Sign…….………………………………………….
Surgeon Print Name …………………………………. Change Over Count / Scrub Print...……………………………….
Signature ………………………………………………….. Change Over Count / Scrub Sign……………………………………

Page 31 of 38
Blood Loss Record

Tray Labels and Traceability Stickers

Page 32 of 38
 The Newcastle upon Tyne Hospitals NHS
NHS Foundation Trust
PERI OPERATIVE THEATRES COUNT SHEET OBSTETRIC THEATRES

Hospital RVI Surname MRN Number

Theatre Forename D.O.B.
Date Address NHS No
Surgical Count this is a record of the number of, variety of swabs and Sex Male/ Female
instruments used within the perioperative fields etc., during the operation
performed on the above named patient.

count count count

1 2 3
Mops 30 x 30

Mops 10 x 15

Packs 45x45

Vag Roll

Blades

Atraumatics
Hypodermics

TRAYS :-

LSCS
PROCEDURE
30 TEAR
C x SUTURE
ERPC
HYSTERECTOMY
RETRACTOR

EXTRAS

INTENTIONALLY RETAINED GAUZE

Type/Size ……………………………………….. Amount…………………………………………………………

Surgeon closing the wound has been Scrub Practitioner Print …………………………………………..
informed that the count has been Scrub Practitioner Sign.…………………………………………..
completed and that the count is Correct /
Count Practitioner Print …………………………………………..
incorrect (circle).
Count Practitioner Sign…………………………………………….
Surgeon Print Name ………………………………….
Change Over Count / Scrub Print…………………………………
Signature ………………………………………………….. Change Over Count / Scrub Sign….………………………………

Page 33 of 38
BACK PAGE

TIME IN - LEGS UP -

KTS - LEGS DOWN -

TOB -

TOP - TIME OUT -

Blood Loss Record

LIQUOR

BLOOD
BLOOD
BLOOD
BLOOD
BLOOD
BLOOD
BLOOD
BLOOD
BLOOD
BLOOD

TOTAL

Tray Labels and Traceability Stickers

Page 34 of 38
 Affix patient identification label in box below or complete details
Surname Patient I.D No.
Forename D.O.B.
Address NHS No.
Sex. Male / Female

Postcode

Adult Cardio-Thoracic Theatre – Integrated care pathway

Instrument Tracking Record

Has the Bar Code Identification been entered on the computer system? Yes No

Attach bar code stickers

Date: - Name: - Signature:-

Page 35 of 38
 Appendix 2

Action to be taken following Report of Missing Instrument by SSD Supervisor

SSD Staff

Date & Time Reported …………………………………………………………………………………..

Instrument(s) Missing……………………………………………………………………………………..

Tray (& number if appropriate)……………………………………………………………………………

Reported to Sister………………………………………………………………………………………….

Speciality……………………………………………………………………………………………………

Supervisor Reporting Incident ……………………………………………………………………………

SSD Supervisor / Deputy must now send this form to the Sister in Charge of the Speciality
for completion Theatre Staff

Date and Time Tray

Used……………………………………………………………………………………

Theatre
Number………………………………………………………………………………………………..

Scrub
Person…………………………………………………………………………………………………..

Actions Tick Box Undertaken by Date

Taken (Print Name)

Laundry searched

Rubbish searched

Count/instrument sheets checked

Discuss with Scrub Person

Discuss with Count Person

Discuss with surgeon

Instrument found (Delete as appropriate) YES signed / Date ………………………………………..

Instrument NOT found

Action Taken (Please document date and time instrument replaced)

Speciality Sister’s Signature …………………………………..Date………………………………………

Page 36 of 38
 Appendix 3

Action to be taken following report of missing instrument by Theatre staff

1. THEATRE STAFF

Date and time

reported

Instrument(s)
missing

Tray (and number if appropriate

Theatre
number

Scrub
Nurse

Tray and contents searched

by

Repair database checked

by

Instrument sent for repair? (Circle) YES NO

Reported to SSD supervisor

by

SSD Instrument sheet signed

by

Documentation of missing instrument

2. Sterile Services Department

Reported to
supervisor

Date/time

Page 37 of 38
 Action taken Tick box Undertaken by date

Search washing area

Search packing area

Discuss with tray signatory

Discuss with tray check signatory

Instrument Found (Delete as appropriate) YES Signed / Date

Instrument not found

Action taken (please document date/time replaced)

Signature of SSD manager

Page 38 of 38
 The Newcastle upon Tyne Hospitals NHS Foundation Trust
Equality Analysis Form A

This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration
and approval.

PART 1

1. Assessment Date: 15/11/2017

2. Name of policy / strategy / service:

Count Procedure Policy

3. Name and designation of Author:

Claire Winter, Sheina Baldwin,

4. Names & Designations of those involved in the impact analysis screening process:
Claire Winter, Sheina Baldwin, Gill O’Meara

5. Is this a: Policy X Strategy  Service 

Is this: New  Revised X

Who is affected: Employees X Service Users  Wider Community 

6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and
pasted from your policy)

The aim of this policy is to standardise the procedure for accounting for all swabs and instruments used during operative
procedures.

This policy is of primary interest to all Theatre Nursing, Non-Nursing Staff and Operating Department Practitioners when
performing count activities.

Count Procedure Equality Analysis form Nov 2017 Page 1 of 4 Dec 2013
7. Does this policy, strategy, or service have any equality implications? Yes  No 

If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis
Guidance before providing reasons:

8. Summary of evidence related to protected characteristics

Protected Evidence i.e. What evidence do you Does evidence/engagement Does the evidence highlight any
Characteristic have that the Trust is meeting the highlight areas of direct or areas to advance opportunities
needs of people in various protected indirect discrimination? If yes or foster good relations. If yes
Groups related to this describe steps to be taken to what steps will be taken? (by
policy/service/strategy – please refer address (by whom, completion whom, completion date and
to the Equality fact files available via date and review date) review date)
the link below (add link)

Race / Ethnic No No
origin (including The policy does not discriminate on the grounds
of race/ethnic origin, sex, religion and belief,
gypsies and sexual orientation, age, disability, gender
travellers) reassignment, marriage and civil partnership and
maternity and pregnancy.

Sex (male/ female) As above No No

Religion and Belief As above No No

Sexual orientation As above No No

including lesbian,
gay and bisexual
people
Age As above No No

Count Procedure Equality Analysis form Nov 2017 Page 2 of 4 Dec 2013
Disability – As above No No
learning
difficulties,
physical disability,
sensory
impairment and
mental health.
Consider the
needs of carers in
this section

Gender Re- As above No No

assignment

Marriage and Civil As above No No

Partnership

Maternity / As above No No
Pregnancy

9. Are there any gaps in the evidence outlined above. If ‘yes’ how will these be rectified?

No

10. Engagement has taken place with people who have protected characteristics and will continue through the Equality
Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in
respect of any significant changes to policies, new developments and or changes to service delivery. In such
circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer.

Do you require further engagement Yes No X

Count Procedure Equality Analysis form Nov 2017 Page 3 of 4 Dec 2013
11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and
family life, the right to a fair hearing and the right to education?

No

PART 2

Signature of Author
Claire Winter, Sheina Baldwin

Print name

Date of completion
24/11/2017

(If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy
Author identified above, together with any suggestions for action required to avoid/reduce the impact.)

Count Procedure Equality Analysis form Nov 2017 Page 4 of 4 Dec 2013