Easier, quicker, safer: an enhanced instrument count procedure

In 2018 a serious incident occurred during surgery at the Nuffield Orthopaedic Centre (NOC). Following a hip replacement operation, an acetabular trial (an instrument for checking fit before the final components are inserted) was identified as missing by the theatre sterile services unit (TSSU). An X-ray revealed that the instrument had been left inside the patient. The resulting investigation introduced improved accountability for instruments through a temporary instrument count procedure (TICP), with nursing staff being required to count each item on the surgical trays individually, both before the start of the surgical procedure and at the conclusion of the operation, but ahead of wound closure. Given that some orthopaedic procedures use up to 25 trays with potentially more than 70 items per tray, the requirements of the TICP, introduced with immediate compliance, posed a significant challenge for the surgical teams.

With individual instrument counts taking up to 30 minutes to complete, the disadvantages introduced by the TICP included: