Incorrect Surgical Counts: A Qualitative Analysis

Ensuring that patients remain free of unintended retained foreign bodies is a primary responsibility of perioperative nurses and surgical technologists. However, these incidents continue to occur despite hospital policies and AORN recommended practice guidelines for their prevention. To provide insight into how incorrect surgical counts occur, researchers conducted a qualitative analysis of the tasks and challenges faced by perioperative nurses and surgical technologists in an academic medical center and a community hospital. Using hermeneutic phenomenological methodology, we identified bad behavior, general chaos, and communication difficulties as problems associated with incorrect surgical counts. As point-of-care providers, perioperative RNs are well poised to identify problematic areas and design systems and processes that protect patients. Perioperative RNs should consider using red rules or a code of conduct as tools for improving the manual counting process. These strategies could be developed in the shared governance council or a perioperative staff-led committee to ensure adherence to AORN standards.