How can missed instruments during surgical procedures be avoided?

Preventing Missed Surgical Instruments

Both systematic instrument counting and formal sign-out procedures are essential to prevent retained surgical items, with counting protocols being the primary defense and sign-out serving as a critical verification checkpoint. 1, 2

Primary Prevention: Systematic Instrument Counting

Implement mandatory counting protocols at multiple time points during every surgical procedure. 1, 2 The evidence demonstrates that instrument tracking systems and standardized counting procedures are fundamental to preventing retained items:

• Perform counts before the procedure begins, before closure, and at skin closure to establish baseline inventory and verify completeness at critical junctures 3, 2
• Use surgical instrument tracking systems in the central sterile supply department to document packaging accuracy and identify discrepancies before instruments reach the operating room 3
• Assign dedicated personnel (typically the scrub nurse and circulating nurse) to perform counts together, with both verbally confirming numbers 1, 2

Secondary Verification: Formal Sign-Out Procedures

Incorporate instrument count verification into the surgical safety checklist and sign-out process. 1, 2 This creates a mandatory pause point:

• Document all counts in the operative record before the patient leaves the operating room, with signatures from both counting personnel 1, 2
• Prohibit patient transport until count reconciliation is complete and any discrepancies are resolved 1, 2
• Include count status in the formal surgical timeout/sign-out, making it a team responsibility rather than solely a nursing task 2

Addressing Common Error Patterns

The research reveals specific high-risk scenarios requiring extra vigilance:

• Wrong instrument specifications and missing instruments account for the majority (63%) of packaging errors, with 77 missing instruments documented in one study of 33,839 packages 3
• Least experienced staff (N1 level nurses) and late shifts (16:00-20:00) demonstrate significantly higher error rates, requiring enhanced supervision during these periods 3
• Orthopedic and gynecology/obstetrics departments show relatively higher error rates, likely due to complex instrument sets 3

Critical Pitfalls to Avoid

Never allow the surgical team to leave the operating room until counts are reconciled. 1 Poor communication is the most common root cause of retained surgical items 2:

• Do not proceed with closure if counts are incorrect - obtain imaging (X-ray) to locate missing items before completing the procedure 2
• Avoid excessive staff movement during procedures, as this increases the risk of instruments being displaced or miscounted 1
• Minimize equipment in the OR to only what is necessary for the specific procedure, reducing the complexity of counting 4, 1
• Standardize instrument sets within surgical specialties to reduce confusion about expected contents 3

Quality Control Measures

Establish institutional protocols for instrument quality and tracking: 3, 5, 6

• Implement pre-operative instrument inspection to identify malfunctioning or damaged instruments before they enter the sterile field, as equipment failure occurs in 92% of cardiac procedures 6
• Use indicator systems (such as barcoding or RFID tracking) to verify instrument presence in packages before sterilization 3
• Conduct regular audits of counting compliance and error rates, with feedback to staff 3

The evidence strongly supports that both counting and sign-out are complementary rather than alternative strategies - counting provides the mechanism for detection, while sign-out ensures accountability and prevents premature case completion 1, 3, 2.