Running head: REFLECTION ASSIGNMENT
Natasha Kotzmoyer
Reflection Assignment
Liberty University
REFLECTION ASSIGNMENT
Have you ever felt that one moment in your nursing career when you heart quickly drops
down to the pit of your stomach and all you can think to yourself is, “oh no, oh no this cannot be
happening?” I think all of us as nurses at one point or another have felt that dreadful feeling of
doom due to a patient error.
I had been a nurse for little under a year working in the operating room. It was about
12:30 at night when the supervisor had called the call team informing us there was a gentleman
in the emergency room with a bowel obstruction that was requiring an exploratory laparotomy,
possible bowel resection, possible colectomy. Those middle of the night phone calls are always
ones the operating room staff never look forward to.
When we got to the hospital I, as the circulating nurse went to interview the patient
while the team set up the operating room. The scrub nurse and I had completed the first count
prior to the start of incision. During the procedure instruments had been added to the field and
had been counted as soon as they were received by the scrub nurse. It was about 3:00 in the
morning when the scrub nurse and I were getting ready to complete our first closing count when
we realized that there was a forcep instrument missing. We immediately recounted to confirm it
was not just a counting error. We checked floors, double checked the surgeon to make sure that
it wasn’t in use. The forcep was nowhere to found. Due to this procedure being a large open
belly case I began to really worry that perhaps the forcep was left inside the patient.
At this point, the surgeon was getting ready to close skin and I knew we were going to
have to call the x-ray technologist to come into the OR to scan the patient to confirm there was
not a retained forcep in the patient. Anesthesia had to keep the patient intubated while they
brought the x-ray machine in to scan the patient’s abdomen and then the team had to continue to
wait for the radiologist to read the scan to determine whether the missing forcep was in fact
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inside the patient. The procedure was delayed about 30 minutes before the radiologist confirmed
there was no retained instrument inside the patient. The surgeon was then able to continue
closing the patient’s abdomen and anesthesia was able to proceed with extubating
For those of you unaware of operating room policy and procedures, each facility is
required to have a standard policy and procedure for surgical counts. The policy should include
when the counts should be performed, by whom should do the count, what surgical items should
be counted, and how counts (including counts that are incorrect) should be documented. Most
established protocols require a count to be performed by the circulating nurse (RN) and the scrub
nurse (Fencl, 2016). A full count includes sponges, sharps, and instruments. Instruments should
be included on the count any time the peritoneal, retroperitoneal, pelvic and thoracic cavities are
entered. Any time an item or instrument is added during the procedure it should be added to the
count sheet. Anytime there is a discrepancy in the count, the OR team should immediately
perform a recount, if they are still unable to find the missing item, they should immediately
notify the rest of the team and the surgeon, so everyone can begin looking for the missing item.
If the item is still not found a radiograph should be taken upon completion of the procedure to
confirm there is not a retained item still inside the patient (Fencl, 2016).
With such an extensive surgical count policy and such strict guidelines, many may
wonder how the operating room staff could possible leave a retained surgical item inside the
patient. Believe it or not, 1,500 operations result in retained surgical items every year in the
United States (Judson, Howell, Guglielmi, Canacari, & Sands, 2013). This can result in serious
illness and even morbidity. A recent study showed that increased case duration and the number
of providers present were independently related to more than doubling the chances of an
incorrect count (Judson, Howell, Guglielmi, Canacari, & Sands, 2013).
REFLECTION ASSIGNMENT
After spending that night in the operating room terrified that we as operating room staff
left a retained object inside our patient, I began thinking about how things could have been done
differently to change the outcome. The first mistake that was made was that fact that when I had
added instruments to during the case, the scrub nurse would count what she received but I didn’t
always watch her count and look at each instrument. This was a completely incorrect on my
part. There is a reason 2 individuals are required to perform a count together and that is so both
sets of eyes are on the items being counted. Since that night, I will always watch the instruments
being counted for every case and if I am unable to see what is being counted I will asked the
scrub nurse to show me.
I personally am not a fan of the fact we as nursing staff are required to work 40 hours a
week in addition to call. This means that we could work an 8-hour day, get called in that night
and work the entire night and then be expected to work the next day. If we do get called in and
work in the middle of the night, management will try to send the team home as soon as they can,
but the decision is always based on the patient schedule that day. I believe this is a true safety
hazard and leaves potential for patient error. I have addressed my concerns a few times to the
management team, but it has been a working progress.
The operating room team and myself also learned that counts should not be taken lightly.
Although, you think it would never happen, retained objects in patients does happen and it
happens more often than what most individuals think. Counts require 100% attention of the
circulation nurse and the scrub nurse at the time of counts. It can sometimes be difficult when
the surgeon is requesting something, staff are talking, anesthesia is asking a question. It does not
matter what is going on in the room, the surgical count should take priority at that time. If there
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is uncertainty or question about what was just counted it is vital for the other team member to
speak up and ask to repeat the count.
The forcep was eventually found underneath the bed. It was not found until the bed was
moved during turnover to mop the floors. How relieving to know that the forcep was eventually
claimed and where it was supposed to be. Although, that call night became a tired dreadful
night, it was a night I will not forget and most definitely learned from. Our patient remained safe
considering the circumstances and we as operating room staff took a personal lesson home with
us that night.
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References
Fencl, J. L. (2016). Guideline Implementation: Prevention of Retained Surgical Items. AORN
Journal, 104(1), 37-48. doi:10.1016/j.aorn.2016.05.005
Judson, T. J., Howell, M. D., Guglielmi, C., Canacari, E., & Sands, K. (2013). Miscount
Incidents: A Novel Approach to Exploring Risk Factors for Unintentionally Retained
Surgical Items. The Joint Commission Journal on Quality and Patient Safety, 39(10).
doi:10.1016/s1553-7250(13)39060-6
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