Standard Operating Procedure - Accountable Items Check (including Surgical Swabs, Instruments, Needles and Blades)

(Accountable Items used during all Surgical/ Invasive Procedures in all Operating Theatres and outlying Surgical and Interventional Areas)

1. Introduction
   1.1 Purpose
   1.2 SOP Statement
   1.3 Accountable Items
   1.4 SOP Objectives
   1.5 Consultation
   1.6 Related Procedural Documents
   1.7 Legal Liability
   1.8 Health and Safety
2. Education/Training
3. Duties of the team
   3.1 Key Principles of Accountable Items Checks
   3.2 Change of personnel during operating procedure
4. Procedure for checking & counting
   4.1 Surgical Swabs
   4.2 Swabsafe
   4.3 Surgical Swabs and catheterisation
   4.4 Incorrect number of Raytec Surgical Swab Items on opening the packet
   4.5 The use of Surgical Swabs as packs for a period of time during the procedure
   4.6 The procedure for checking and counting sutures and blades
   4.7 The procedure for checking and counting of instrumentation
   4.8 If an instrument breaks or is found to be faulty during use
   4.9 The procedure for the checking of all disposal accountable items
   4.10 When the accountable item checks must take place
5. Visual & documentary actions
   5.1 Accountable Items Record
   5.2 Whiteboard
6. Wound dressings/tourniquets/throat packs
   6.1 Wound Dressings
   6.2 Use of Finger / Toe Tourniquets
   6.3 Throat Packs
7. Process to be followed for
   7.1 Emergency Surgery
   7.2 Two Incision and Two Team Surgery (e.g. AP Resection)
   7.3 Two or more site surgery and One Team (Scrub Practitioner)
   7.4 Delivery Suite and Obstetrics Theatres
8. The benching of organs (transplants)
9. Procedure to be taken/escalation if
   9.1 Insufficient time (Appendix 5)
   9.2 Accountable Item check discrepancy process (Appendix 6)
   9.3 Microscopic Missing Items
   9.4 If an Accountable Item is discovered on the floor during the procedure
   9.5 Intentional Retention of Surgical Swabs as a pack
   9.6 Removal of the intentionally retained surgical swab (used as a pack)
   9.6b Vaginal packs
   9.7 On discovering a mistake in any Accountable Items Check
   9.8 If a Patient is returned to the Operating Theatre / Procedure Room for removal on Unintended Retained Item(s) (A Never Event)
10. Process for monitoring compliance and effectiveness of this SOP
    10.1 Audit standards

Appendices & References
Appendix 1 - Masterclass
Appendix 2 - Competency Assessment Document
Appendix 3 - Risk Assessment Document for new Accountable Items
Appendix 4 - Throat Pack ‐ Operational Guide
Appendix 5 - Actions to take if insufficient time is given by the Surgeon for Completion of Accountable Items checks
Appendix 6 - Accountable Items Check Discrepancy Process Operational Guide
Appendix 7 - Audit Tool
Appendix 8 - How to Perform an Accountable Items Check in Practice
Appendix 9 - Documentation Atraumatics and Valve Needles in Cardiac Surgery
Appendix 10 - Documentation of Patties
Appendix 11 - Documentation of K-Wires and Guide Wires
Appendix 12 - Radiological intervention - Operational Guide
Appendix 13 - Invasive Procedure Flowchart
Appendix 14 - Wrong operation / side / site / implant process operational guide

1.0 INTRODUCTION

The Accountable Items Check plays a vital role in enabling the perioperative and interventional teams to enhance patient safety. All items, for example instruments, surgical swabs and sutures used by the perioperative and interventional teams to perform invasive procedures, are foreign bodies to the patient and must be accounted for at all times to prevent retention and injury to the patient. This is to reduce or eliminate never events.

The Definition of a Never Event (in this context) is:

The unintended retention of a foreign object in a patient after surgical intervention, including interventional radiology, cardiology, and vaginal birth.

Retained objects are considered a preventable occurrence and careful counting and documentation can significantly reduce, if not eliminate, these incidents. Retained foreign objects can include instruments, surgical swabs, sutures and other accountable items (see 1.3)

The never event definition excludes where any items are knowingly missing prior to the completion of the surgical intervention and are within the patient, but where further action to locate and / or retrieve would be more damaging than retention, or impossible. This must be documented in the patient’s notes and the patient informed. A Datix form must be completed and the missing item be documented in perioperative the record of care.

• Throughout the SOP, whenever the term Theatre is used it also includes interventional procedure rooms
  / radiology / endoscopy / OPD clinic rooms / treatment rooms for example, any room where a surgical or interventional procedure takes place.
• Definitions - This SOP outlines the responsibilities of all staff in relation to Accountable Items Checks.
  ‘Surgical Staff’ all members of the medical team performing surgical procedures or interventions.
  ‘Registered Practitioners’ either a Registered Nurse or Registered Operating Department Practitioner (ODP) Registered Nursing Associate or Midwife, Registered Dental Nurse and Registered Radiographers.
  ‘Advanced Perioperative Assistants’ denotes a Perioperative Assistant assessed to Level 3 Diploma in peri-operative support and in a Band 3 role and competent to act as Scrub Practitioner for a defined set of clinical procedures within their surgical speciality.
  ‘Non registered Practitioners’ denotes a Perioperative assistant or Support Worker who has been assessed competent in conducting Accountable Items Checks as a Circulator Practitioner.
• Team Leader denotes staff equivalent to Band 7.

1.1 Purpose
This SOP is to assist all staff in any area undertaking surgical / interventional procedures to carry out their duties in the checking and recording of Accountable items. The SOP is designed to guide staff when discrepancies occur and ensure that the patient receives optimum care. In addition it has been developed to ensure that all staff do not breach their duty of care and are aware of each individual’s responsibility and accountability for checks during a surgical / interventional procedure.

1.2 SOP Statement
The overriding principle is to ensure that all instruments, surgical swabs, sutures and other miscellaneous items are accounted for throughout surgical / interventional procedures to prevent foreign body retention and subsequent injury to the patient. Although it is the responsibility of the Surgeon / Operator to return all items, the Scrub Practitioner implements the checking procedure in order to be able to confirm that all items have been returned and are accounted for.

1.3 Accountable Items
Accountable Items shall include, but are not limited to: x-ray detectable surgical swabs, packs, peanuts / pledgets (Laley Surgical Swabs), gauze strips, neuro patties, needles, instruments, including screws or detachable parts, blades, local infiltration needles, tapes, slings, liga packs and reels, sloops, shods, bulldogs, sponges, red swab / packs ties / tags, cotton wool balls and disposable items, e.g. trocars and cannula, Guide wires and introducers, staple gun, staple gun reloads, sutures, syringes, needles, retrieval bags, ligaclip applicators and reloads. If drug ampules are being opened into the sterile field and being retained to be checked by the Surgeon they should be accounted for on the accountable items record.

1.4 SOP Objectives

• To reduce the risk of an inaccurate accountable items check being undertaken, by ensuring that all checks are undertaken by two competent individuals.
• To enforce a uniform method of preparation to safely account for surgical swabs, instruments, sutures and miscellaneous items.
• To facilitate good communication and team work and avoid any misunderstanding.
• To promote an optimal surgical / interventional patient outcome.
• To ensure consistent practice across the Trust, wherever accountable items are used.
• To eliminate the avoidable error of retained objects post-surgical / interventional procedure - a‘Never Event’

1.5 Consultation
The following disciplines have been consulted:

• Consultant Anaesthetists
• Consultant Surgeons
• Heads of Nursing
• Matrons
• Perioperative Practitioners
• Practitioners outside of Operating Theatres but undertaking interventional / surgical procedures
• Risk Management.

1.6 Related Procedural Documents

• Risk Management Policy
• DATIX Incident Reporting and Trigger Lists
• SOP Operating Theatre Etiquette and Acceptable Behaviours
• Implant SOP
• Cataract lens implant SOP

1.7 Legal Liability
The Trust will generally assume vicarious liability for the acts of its staff, including those on honorary contracts. However, it is incumbent on staff to ensure that they:

• Have undergone any suitable training identified as necessary under the terms of this SOP and deemed competent.
• Have been fully authorised by their Line Manager and their CSU to undertake the activity in accordance with their Job Description.
• Fully comply with the terms of any relevant Trust Policies and / or procedures at all times.
• Only depart from this SOP providing always that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such a departure shall only be undertaken where, in the judgement of the responsible clinician it is fully appropriate and justifiable - the decision must be fully recorded in the patient’s notes.

1.8 Health and Safety

• Personal Protective Equipment must be worn at all times
• Ensure hand hygiene practices are followed at all times.
• Ensure that any contaminated equipment is cleaned, and / or sterilised and disinfected as per Trust Policy.
• A safe sharp disposal system is to be used for the storage and disposal of sutures, needles, blades and other sharp items.
• The passing and receiving of needles, sutures and blades must wherever possible, take place using a receiver to reduce risk of sharps injuries.
• Linen and waste bags must be labelled with the date, theatre (or room) number, case order and also the session if more than one session is undertaken in that theatre on that date.
• All items must be accounted for and removed from the theatre at the end of each procedure.

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2.0 EDUCATION/TRAINING

• The SOP accountable items Masterclass (Appendix 1) must be included in the local induction programme for all new perioperative staff, maternity staff and in areas outside of operating theatres where interventional/surgical procedures take place. All New starters will be advised where to find a copy of the SOP for Accountable Items on the T&A webpage
• A copy of the SOP is to be issued to all new medical personnel (Surgeons / Interventionists and Anaesthetists) who must also undertake the E-Learning competency as part of their induction.
• All practitioners must accept responsibility for updating their knowledge and skills to undertake and maintain competency assessment every three years (Appendix 2). Further Masterclass training and assessment will be undertaken following incidents / near misses / never events as indicated by the investigation team.
• Student ODPs, TNAs and nursing students are supernumerary therefore two other competent members of staff must be involved in the checks (one of whom must be qualified).
• Agency staff must read Appendix 8 ‘How to perform an accountable items check in practice’ before they take part in any aspect of the check

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3.0 DUTIES OF THE TEAM

3.1 Key Principles of Accountable Items Checks

• All staff are to maintain a safe standard of accountable items checks in compliance with this SOP.
• All accountable item records will be revised and updated every 3 years by the Team Leader or sooner if required.
• Prior to the commencement of any surgical operation / interventional procedure, the operating theatre or room is checked to be free from instruments, surgical swabs, sharps, clinical waste and linen from the preceding operation / procedure. The whiteboard must be wiped clean.
• During the operation / procedure, all accountable items, clinical waste and linen are to remain in the operating theatre/room. When the final check has been completed these items must only be removed at the direction of the Scrub Practitioner.
• No items should be removed from the sterile field / trolley unless directed by the scrub practitioner.
• Prior to commencement of the proposed operation / procedure, all clinical bags are labelled with the date, theatre or room number, and case order number of the patient.
• The operating theatre must have a whiteboard displaying all the accountable items used.
• The whiteboard must be visible and accessible to every team member.
• All accountable items are recorded on the whiteboard in the theatre and also on the Accountable Items Record.
• If an assessment of blood / fluid loss from surgical swabs is required, this must be documented on the whiteboard and the information shared with the surgeon and anaesthetist.
• All checks must be conducted by two competent members of staff, one of whom must be a registered practitioner.
• If a student is in the scrub practitioner role, there must be two other practitioners involved in the check, one of whom must be the registered practitioner who is supervising the student. All three must sign the Accountable Items Record.
• Visitors / Company representatives must never participate in any checks.
• Visiting retrieval teams must carry out all accountable items checks with a competent member of Trust staff.
• The scrub practitioner must take the lead for commencing accountable items checks.
• This must be done in a systematic manner involving the circulating practitioner. Both members must count audibly and in unison with each other and observe the items.
• Instrument checks must be read out by the circulating practitioner and the instruments and items demonstrated by the Scrub Practitioner.
• Accountable items checks must be performed for all surgical / interventional procedures and recorded on the Accountable Items Record and whiteboard.
• The Accountable Items Record must be filed in the patient’s case notes at the end of the procedure.
• An accountable items check must be completed immediately prior to surgery commencing, subsequent checks shall occur as a minimum before the closure of a cavity, following skin closure or following completion of procedure.
• If a scrub practitioner is not required for the procedure (e.g. dilatation and curettage), the circulating practitioner must be a registered practitioner with whom the operating surgeon must perform the checks.
• Sterile trolleys must only be set up for one patient at a time. The practice of setting up numerous trolleys for a list of patients is not acceptable.
• All new or temporary accountable items must be risk assessed prior to initial use to identify how they will be checked / counted and recorded. This must be documented on the Risk Assessment Form and communicated to all of the team (Appendix 3).
• When accountable items are being checked either pre-operatively, intra-operatively or post- operatively there must be no interruptions
• When conducting the post-operative check the scrub practitioner must inform the surgeon so that they are aware not to interrupt. During this stage of the procedure there must be a surgical pause in which the operating clinician checks the wound site. An announcement should be made to state that the first post-operative check is going to be carried out.

3.2 Change of personnel during operating procedure

• The scrub practitioner should ideally be the same person for the whole procedure. During prolonged procedures (e.g. major head and neck) where changeovers are planned, this should occur in agreement with the Surgeon and at a time deemed appropriate. Planned changes should be discussed at the Team Brief prior to the start of the list.
• If there is a planned or unplanned changeover of scrub practitioners, it must be discussed with the surgeon and a suitable time frame agreed. Agreed changeover of scrub practitioners should be discussed at team brief and documented.
• In exceptional circumstances, where more than one unexpected/unplanned changeover of scrub practitioner is undertaken, this should be logged as an incident in DATIX.
• If there is a planned or unplanned changeover of scrub practitioner for any reason during the procedure, a complete check of all accountable items (as practicably as possible) must be performed.
• This must happen between the incoming scrub practitioner, and with reference to the outgoing scrub practitioner, with the circulating practitioner at the changeover. The Perioperative Care Plan, Theatre Management System (TMS) where used, and Accountable Items Record must be signed by all practitioners involved.
• If there is a changeover of circulating practitioner, there must be a handover provided by the first circulator leaving the Operating Theatre Room. The time of changeover must also be clearly recorded in TMS and in the Accountable Items Record.
• At this time the surgeon should be informed that a count is being carried out and no interruptions should take place.
• In the event of a count discrepancy, there should be no changeover of staff at that time.
• In the event of scrub practitioners being relieved for a short period of time, in which the relieving practitioner is from the same team a verbal check of swabs and sharps should be a minimum.
• The scrub practitioner who is being relieved must prepare by opening and accounting for sterile items that may be needed during their temporary absence (as far as is reasonably practicable) to reduce risk
• Where the relieving practitioner is not part of the original team a full accountable items check must be carried out as a minimum, between the incoming scrub and the circulating practitioner
• All relieving practitioners’ names must appear on the Accountable Items record and in TMS

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4.0 PROCEDURE FOR CHECKING & COUNTING

4.1 Surgical swabs

• All surgical swabs must be white and packed in bundles of five or ten held together by a red tie
• Surgical swabs are named by their size e.g. 10 x 10, 36 x 11
• Each size of surgical swab must be counted in turn and recorded on the accountable items record sheet and written on the whiteboard. At this point the RAYTEC must be checked to be intact and if applicable, the tape firmly attached.
• Each size of surgical swab must be counted singly into separate piles of 5 or 10 and then documented as a running total on the accountable items record and the whiteboard.
• Surgical swabs must not be cut or wilfully damaged at any time. It is unacceptable to remove the Raytec marker.
• Each red tie must be counted as part of the pack of surgical swabs, documented on the accountable items record sheet and written on the whiteboard and kept securely on the trolley. When surgical swabs are counted into the swabsafe the appropriate size red tie must also be placed in the container. The remaining ties on the trolley must match with the number of remaining packs of surgical swabs within the operative field and on the trolley.
• If a patient undergoes several procedures at the same time, all surgical swabs must be checked at the end of each procedure and new checks commenced for the next. All accountable items pertaining to the patient must remain in the Operating Theatre until all procedures are completed and only removed on the instruction of the Scrub Practitioner.
• Raytec surgical swabs must not be used to dress surgical wounds.

4.2 Swabsafe

• Swabsafe is designed to reduce the risk posed to individuals by the unnecessary handling of contaminated surgical swabs and assist in accurate surgical swab counting.
• Swabsafe must be used for all procedures
• During routine, controlled surgical procedures individual swabs are placed into the swabsafe as they are ready to be discarded
• During any time when there is excessive bleeding or the scrub practitioner cannot concentrate on the process the used swabs are placed in a receiver or bowl until a time that both the scrub and circulating practitioners can concentrate on checking and filling the swabsafe correctly
• The scrub practitioner fully opens the surgical swab to demonstrate to the circulating practitioner that there is only one surgical swab and the size.
• The scrub practitioner then rolls the surgical swab and places it neatly into the corresponding size compartment within the swabsafe container. The circulating practitioner must ensure that the swab is neatly contained within one compartment. If there is any part of the swab overhanging into the next section the circulating practitioner must ensure this is pushed into the correct section using a rampley forceps to do so.
• Once all five sections are filled, the scrub and circulating practitioners check together and out loud that there are five surgical swabs present.
• The scrub practitioner then adds the relevant size red tie into the container.
• The circulating practitioner ensures the lid is secured an d the swabsafe container is taken from the stand and placed on the floor under the whiteboard.
• Further swabsafe containers of the same size can be stacked on top until the checks are completed.
• During the final count any swabsafes that have been started must be filled with the remaining swabs.
  Swabs in quantities of five that have not been used may be discarded off without a swabsafe.
• On commencement of all accountable item checks, the surgical swabs in the sealed swabsafe containers are checked first, then those in the open swabsafe container, the surgical swabs on the sterile trolley and finally the surgical swabs on the patient or in the wound. If the count is interrupted it must be recommenced from the beginning.
• If during a procedure there is a large amount of swabs used, the completed swabsafe container of the same size swabs can be bagged in multiples of 25 (5 completed swabsafes) The bag must be labelled clearly with the size of the swab, the number of swabs inside and be initialled by the circulator. They remain part of the check at the end of the procedure. The scrub and circulating practitioners must check the number of swab safe containers twice before placing in the bag
• BLOOD CLOTS MUST NEVER BE PLACED IN SWABSAFE CONTAINERS.

4.3 Surgical Swabs and Catheterisation

• Catheterisation packs should be used for the catheterisation of patients.
• If catheterisation is performed as part of or during surgery (e.g. gynaecology) X-Ray detectable surgical swabs must be used and accounted for by the scrub and circulating practitioners, on the Accountable Items Record and on the whiteboard.

4.4 Incorrect number of Raytec Surgical Swabs on opening the packet

• In the event of an incorrect number of surgical swabs, or sundry items being present when opened, the entire packet and its contents must be immediately removed from the Operating Theatre / Room, placed in and retained in a sealed bag.
• The Supplies Department should be contacted and in turn contact the relevant Company at the earliest opportunity, where they may check the batch number for further discrepancies.
• It is the responsibility of the Perioperative / Interventional Team to ensure that a DATIX incident is reported.

4.5 The use of Surgical Swabs as packs for a period of time during the procedure.

• Surgical swabs can be used as haemostat packs during procedures. The size and number of surgical swabs used must be documented on the whiteboard plus the time inserted.
• When the surgical swabs are removed from the wound / cavity, the scrub practitioner must show the surgical swabs to the circulating practitioner to acknowledge the items and the circulating practitioner must document that the surgical swabs have been removed and the time on the whiteboard. The surgical swabs are then placed in the swabsafe.
• This includes when swabs are being used as packs behind retractors.
• If a patient is transferred to PACU with a pack insitu (e.g. dental pack) the scrub practitioner must hand over to the PACU staff, who must document the pack’s removal

4.6 The procedure for checking and counting sutures and blade

• The suture check must include checking the actual number of suture needles in each pack, e.g. when there are 8 needles in one packet, 8 needles must be counted.
• Suture packets and plastic covers from eyed needles must be kept as the additional method of checking total numbers in use, and these are counted at each accountable items check.
• Atraumatic sutures are documented as a running total and recorded on the Accountable Items
  Record and the whiteboard.
  Sticky Sharps Securing Devices (discard-a-pads) or suture boxes must be used, for safekeeping and disposal of all sharps. The covers must always be removed from the adhesive surface of the securing device, to aid easy observation during checks.
• Blades must be counted and documented on the Accountable Items Record and whiteboard as a running total number.

4.7 The Procedure for Checking and Counting Instrumentation

• Instrument trays and supplementary instruments must be checked to ensure their sterility prior to opening. The instrument packs must be checked by ensuring that either: the autoclave tape has turned from beige to brown striped, the spots on the containers have turned from pink to grey / brown, or the arrows on Genesis tins have turned brown.
• The expiry date on the instrument tray sticker must be checked.
• The tray wraps must be checked before opening for tears or wet patches and the tray rejected and returned for reprocessing. A BBraun PD63 Form must be completed.
• A BBraun tray ID sticky label must be placed onto the back page of the Accountable Items Record.
• The instrument tray check lists must be available for each tray in order to provide accurate, documented and traceable record of instrumentation.
• The pre-printed instrument tray check lists must be used by both the scrub practitioner and circulating practitioner to check the contents of the instrument tray. The circulating practitioner must read the check list out loud, naming the instruments and then tick the relevant boxes to acknowledge that the scrub practitioner has demonstrated to them the presence of each instrument.
• Any missing or damaged instrument must be documented clearly on the tray list and a BBraun PD63 Compliance Form must be completed. Damaged instruments must not be used as a risk to patient safety.
• Broken instruments must be labelled with a description of the damage noted and returned to BBraun for processing (Decontamination Certified) prior to sending for repair.
• If soiled instruments are identified the whole tray must be rejected and a DATIX and PD63 form completed.
• During Pre-operative checks if there is a discrepancy, all the instruments must be taken out of the tray to ensure that no instruments are hidden in the bottom of the tray.
• All instruments must be checked pre-operatively for completeness and function as far as is reasonably possible.
• During the surgical / interventional procedure the circulating practitioner must check as above and record any additional instruments opened on the Accountable Items Record.
• If an instrument is passed off the sterile field, it must be kept safely and within the scrub practitioners vision until the final check has been successfully completed.
• If an instrument is found on the floor it must be identified to the scrub practitioner and placed within his / her vision. A check must be made of all the same instruments on each instrument tray to ensure it is a dropped item and not a missing or an extra item. This check must be documented on the Accountable Items Record and on the whiteboard and include the time when checks were completed and by whom.
• All instruments must be checked after use to ensure they remain complete.
• All parts of a broken or disassembled instrument must be accounted for in its entirety, at all checks.

4.8 If an Instrument breaks or is found to be faulty during use

• All instruments, especially laparoscopic must be checked at the end of the surgical procedure to ensure that they are complete
• If an instrument breaks during use, the scrub practitioner must inform the surgeon and ensure that all pieces / parts are returned and accounted for.
• If they cannot be accounted for the patient must be X-Rayed and the missing pieces retrieved if identified.
• The incident and outcome must be documented in the surgical notes / DATIX and Perioperative Care Plan.
• If the instrument is a disposable item, it may be necessary to inform Supplies and the Manufacturer if a piece of equipment is found to be faulty or fails to work as expected. If in doubt then please discuss with the Team Leader or Deputy Theatre Manager / Matron.
• If a disposable instrument is found to be faulty it must be retained for inspection. The Manufacturer / Company Representative should be informed as they may need to test the instrument. A DATIX report must be completed.

4.9 The Procedure for the checking of all Disposable Accountable Items

• These are any additional pieces of equipment required for the surgical / interventional procedure - please see Section 1.3 Accountable Items for a list.
• All these items must be checked and recorded on the Accountable Items Record and the whiteboard.
• Reels are to be kept away from the open wound when not in use and must be checked as part of the Accountable Items checks. The packets must be kept as an additional check on the total number.
• Items such as slings, which may have been cut down, need to be documented on the Accountable Items Record and the whiteboard. It must include the whole size and how many pieces it has been cut into. Items which are provided with many pieces must have the total number recorded on the Accountable Items Record and the whiteboard.
• Guide wires must be accounted for and the length and tip must be visually checked on removal to ensure that the complete guidewire has been removed Guide wire introducers must also be accounted for on the accountable items records. Both K wires and guidewires must be documented as any other accountable item
• Retrieval bags must be accounted for as an accountable item and must be recorded on the Accountable Items Record and the whiteboard

4.10 When the Accountable Items Checks must take place

• The Accountable Items Checks must be completed at the following times as a minimum:

PRE-OPERATIVELY - Immediately prior to the commencement of surgery / procedure.

INTRAOPERATIVELY - At the closure of every cavity e.g. stomach / uterus / joint cavity / Aneurysm sac / abdominal peritoneum / pelvic peritoneum.

FINAL - At the end of the procedure / following closure of the wound and prior to the dressing being applied.
At any other time deemed necessary, at the discretion of the Scrub Practitioner / Operator/Surgeon

• There must be a surgical pause before the first post-operative accountable items check takes place. During this time the surgeon must check the wound site, to ensure that nothing is unintentionally retained.
• The surgeon must allow sufficient time for all the checks to be undertaken. This includes turning off music and providing a quiet time in order for the entire team to focus on visual and verbal accountable items checks.
• At ‘sign out’ the scrub practitioner must inform the surgeon the result of the checks. Verbal acknowledgement must be received from the surgeon.

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5.0 VISUAL & DOCUMENTARY ACTIONS

5.1 Accountable Items Record

The Accountable Items Record is a formal document which must be retained within the patient’s notes when the procedure is completed. It identifies all of the personnel involved and all accountable items used throughout the procedure including:

• Patient’s details
• All Practitioners at the commencement of the procedure
• All checks completed at each stage of the procedure, initialled by the Circulating Practitioner.
• If the final check was correct
• That the Surgeon acknowledged that the check was correct
• If there was a discrepancy with any part of the check, what action was taken
• If there were any packs remaining in situ
• Evidence of any relieving Practitioners, names, role and time that they relieved
• Any found or dropped Accountable Items during the procedure
• All Accountable Items used and the number used
• All instrument trays or individual instruments used

5.2 Whiteboard
A mobile or static whiteboard must be placed in an area visible to the whole team and be of a size to include the following pre-printed information:

1. Date
2. Patient Name (Pt. Name:)
3. Hospital Number (Hospital No :)
4. Patient Weight (Paediatric only)
5. Allergies
6. All relevant items in use e.g. Surgical Swabs; Sutures; Blades, Ligaclips, Syringes, etc.
7. Inside Items (placed / removed / times)
8. Tourniquet (Tourniquet Time On - Time Off :)
9. Throat Pack in situ / removed
10. Dropped instruments
11. Blood Loss if requested

All items recorded on the Whiteboard must be initialled by the circulating practitioner

How to perform an Accountable Items Check in practice can be found in Appendix 8.

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6.0 WOUND DRESSINGS/TOURNIQUETS/THROAT PACKS

6.1 Wound dressings

• Wound dressing gauze must be blue
• Any wound dressing must not be opened onto the sterile trolley until the relevant wound is closed and the dressing is required.
• In sterile packs that already include dressings such as delivery packs, the dressings must be kept separate and securely away from surgical swabs, to avoid being inadvertently used or moved into the wound.

6.2 Use of Finger/Toe Tourniquets (See NPSA Guidance Appendix 4)

• Finger / toe tourniquets must be specifically designed devices for that purpose (a surgical glove or catheter must not be used)
• All such tourniquets used must be included in the accountable items checks.
• When the tourniquet is applied by the surgeon, the time must be recorded on the whiteboard / Accountable Items Record and in the Perioperative Care Plan.
• When the tourniquet is removed the time must be recorded on the whiteboard / Accountable Items
  Record and in the Perioperative Care Plan.
• If the tourniquet on the finger or toe is sterile, when it has been removed, it must remain on the instrument trolley and checked as all other accountable items.

6.3 Throat Packs

See Operational Guide (Appendix 4)

• Adult throat packs must be x-ray detectable and green in colour.
• Paediatric Neonates may use x-ray detectable ribbon gauze as a throat pack.
• When a full throat pack is not required, the excess should be discarded. Only the section in use should be recorded on the Accountable Items Record and Whiteboard.
• The decision to use a throat pack must be made by the anaesthetist or surgeon for each patient as appropriate. This person must assume responsibility for ensuring the chosen safety procedures are undertaken.
• At least one visually based¹ and two documentary based checking procedure2 are applied whenever a throat pack is deemed necessary.

The person responsible must choose from one of each of the categories below:

¹Procedures involving visual checks

• Whenever possible, if it will not affect the visual surgical field, part of the throat pack must be left protruding out of the patient’s mouth.
• Only if it is obstructing the surgical field should it be ‘tucked in’
• Label or mark the patient on the head with an adherent sticker or marker.
• Label the artificial airway (e.g. tracheal tube, supraglottic mask airway).
• Attach the throat pack securely to the artificial airway.

²Procedures involving documentary checks:

• Formal and recorded two person check of insertion and removal of pack on the anaesthetic chart.
• And record insertion and removal of the throat pack on the whiteboard and on the Accountable Items Record.
• It is the anaesthetic practitioner’s responsibility to record insertion and removal of the throat pack on the whiteboard and on Accountable Items Record, if done so in the anaesthetic role.
• At the ‘Sign Out check’ the Accountable Items Record and the Whiteboard must be checked to agree that removal of the throat pack has occurred - or that the intention is to transfer the patient to PACU with the pack in situ.
• There must be a verbal and documented handover between anaesthetic practitioner and PACU staff if a throat pack has been intentionally retained
• PACU staff must document that they have removed the throat pack
• If a patient is returning to the ward with an intentionally retained throat pack there must be a written and verbal handover to the ward staff.

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7.0 PROCESS TO BE FOLLOWED FOR:

7.1 Emergency Surgery

• This applies to surgery which must be done quickly to save life, limb or functional capacity. This can take place in areas outside of an Operating Theatre environment, for example: ITU / PICU / PACU / Resus area of A&E / Cardiac Catheter Lab.
• When patients are transferred from outside areas such as A&E, A&E staff must use raytex swabs. A verbal handover must be carried out as a minimum between outside area staff and the perioperative staff. If there is any uncertainty about possible retained swabs the patient must be x-rayed before leaving theatre.
• Whenever it is practically possible, accountable items checks should be undertaken as per the SOP, however, due to the urgency of the procedure these may need to be undertaken at an appropriate time when the patient is stable and at a minimum before the final closure. The surgeon must be made aware of this fact to allow time at the earliest opportunity. All surgical swabs used must be
  X-Ray detectable.

7.2 Two Incision and Two Team Surgery (e.g. AP Resection)

• There must be a scrub practitioner and a circulating practitioner for each incision, i.e. a minimum of 4 people excluding the anaesthetic practitioner.
• All accountable items for each incision must be kept separate at all times and recorded on a separate Accountable Items Record and separate Whiteboards.
• Accountable items checks must be undertaken as per the SOP.
• The final check of accountable items must be undertaken by both scrub practitioners and their designated circulating practitioners to avoid the risk of double counting the same item.
• The information from each check must be conveyed to and acknowledged by the surgeon/s and both Surgical Teams.
• The Accountable Items Records for each site must be clearly labelled to state which site the Record relates to.
• Nothing must be discarded from either site until the final count of the final site has been completed and all items have been accounted for.
• For two site surgeries that are carried out by one scrub practitioner, such as D&C and Laparoscopy, one count check is carried out.
• In normal working hours it should be possible to ensure two scrub practitioners and two circulating practitioners are available for a two site surgery. The issue must be escalated to the Theatre Co- ordinator to organise relief from other teams. If adequate staffing is not available elective procedures can postponed.
• During out of hours a discussion must be held at team brief, with the surgeons made aware.
  Perioperative staff are empowered to raise concerns if they feel there is a patient safety issue. Staff must be allowed extra time to carry out accountable items checks if extra staff are not available but the surgery cannot be postponed.
• Should a two site surgery occur out of hours, which would normally require two scrub practitioners, but staffing levels do not support this; the checks should be carried out as for one procedure.
• If there is not the appropriate staffing levels to support having two scrub practitioners, this must be escalated to the Theatre Co-ordinator or Site Managers as appropriate. A DATIX must be completed if necessary.

7.3 Two or more sites and one team (scrub practitioner)

• This refers to two stage procedures such as cardiac, vascular, head and neck and breast.
• An accountable items check must be carried out at each closure of a wound. This must include a surgical pause and the operating surgeon must check the wound that is being closed.

7.4 Delivery Suite & Obstetric Theatres

To avoid discrepancies, when a trial delivery takes place prior to a caesarean section in the Delivery Suite or Obstetric Theatres:

• In the Delivery Suite the Midwife and / or the scrub practitioner must assist the Obstetrician and check all accountable items prior to the commencement of the trial delivery.
• All surgical swabs used during the trial delivery must be accounted for, placed in a swabsafe and labelled ‘trial’ and the time recorded on the whiteboard. An Accountable Items Record must be completed.
• For patients transferred to the Obstetric Theatre from the Delivery Suite with used surgical swabs, the surgical swabs must be counted and placed in a swabsafe marked with the date, delivery room number, patient’s hospital number and procedure. The information must also be recorded on the Maternity WHO Surgical Safety Check Sheet and the Accountable Items Record.
• Instruments and other accountable items used must be checked within the room by two competent practitioners, one of whom must be registered prior to transfer to Theatre.
• The scrub practitioner must prepare for a caesarean section in readiness to proceed, by opening and checking the instrument tray.
• As soon as the trial delivery proceeds to a caesarean section, the additional surgical swabs and supplementary items are opened and checked as per the SOP.
• The final count for caesarean sections is the final vaginal sweep after the wound has been closed.

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8.0 THE BENCHING OF ORGANS (TRANSPLANT)

• There must be a registered practitioner present at the setup of the procedure to check and document all accountable items with the operating surgeon.
• Before the organ is bagged, the circulating practitioner and the surgeon must check all accountable items and instruments.
• The Accountable Items Record must be completed and filed in the patient’s notes with the procedure is complete.
• When a surgeon is a lone scrub practitioner in this role the circulator must be a registered practitioner.

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9.0 PROCEDURE TO BE TAKEN/ESCALATION IF:

9.1 Insufficient time (Appendix 5)

• If insufficient time is given by the surgeon to complete the accountable items check the senior practitioner present in the Operating Theatre / Room must support the scrub practitioner and inform the surgeon that he / she MUST allow time for the checks to be completed.
• If the surgeon continues to compromise the check, the Team Leader or nominated Deputy must be informed to provide support.
• The Team Leader / nominated Deputy will discuss the noncompliance until assurance is given by the surgeon that the accountable items can be checked without compromise.
• If still unresolved the matter must be escalated to the Deputy Theatre Manager or Matron or Anaesthetist and their support requested.
• A DATIX Report must be completed.

9.2 Accountable Item Check Discrepancy Process (Appendix 6)
Following the discovery of an incorrect accountable items check the scrub practitioner must immediately inform the surgeon.

The surgeon at this point must cease the procedure until the item is located.
The patient must remain in the Operating Theatre / Room until the discrepancy is resolved.

All Team members will make a thorough search of the:

• Operative field
• Instrument trolley(s)
• Surgical Drapes
• Swabsafe containers (only opening these if the missing item is not found in another area)
• Specimens (inside the specimen container and specimen itself)
• The floor including under the operating table
• Waste and linen bags
• Under the soles of shoes and boots
• All used gloves
• Prep Room, the Operating Theatre / Room, Sluice Room and Anaesthetic Room (as applicable)
• Search of, and within the wound, is undertaken by the Surgeon.

If the item is not found:

• The Team Leader must be informed
• A plain X-Ray must be performed, even if the item is deemed non-x-ray detectable. A portable X- Ray machine must be used, as image intensifier may fail to locate X-Ray detectable surgical swabs. However, we recognise that it is not always appropriate to transfer patients to and from the operating table onto an x-ray trolley, a c-arm albeit a slightly higher dose negates the need to transfer. The Radiographers would be able to advise the clinician if in doubt.
• The operative site cannot be regarded as clear unless the plain film X-Ray confirms that an item has not been retained.
• The X-Ray must be reviewed and reported by a Radiologist with feedback to the Operating Surgeon
  / Interventionist as soon as practicable. All radiological images relating to an incorrect check must be retained for future reference.
• Within normal working hours, the Team Leader will discuss the issue with the surgeon to ensure that he / she is advised of the missing item, whether it has been found or if it remains un-located. If the Consultant is not present the surgeon must inform them.
• This must be documented by the surgeon / operator in the patient’s notes and in the care pan and if applicable, TMS.
• If the incident occurs during the night or out of hours the Site Manager must be informed.
• If the missing item is located within the patient and it is safe to do so, it must be removed. Another complete accountable items check must be performed, to ensure that the ‘located’ item was the actual missing item. The surgical procedure can then be completed. A DATIX report must be completed with the outcome of the actions. The outcome must also be documented on the Accountable Items Record Sheet.
• If the missing item is located within the patient but it is deemed that the patient is not fit for further examination / re-opening / further surgery to remove the item, the surgeon must make the decision not to proceed in the best interests of the patient. This must be escalated to both relevant CSU Management Teams and the Risk Management Team (Director of Quality and Medical Director) as soon as possible.
• The decision made, a description of the item and its’ location must be documented by the surgeon in the surgical notes. It must also be documented on the Accountable Items Record and the Perioperative Care Plan. A DATIX Report must be completed with a record of the decision making process made to not proceed. The surgeon must discuss this with his / her Clinical Lead and the patient should be informed as soon as possible.
• If the missing item is not located on the X-Ray, another full accountable items check must be completed and the searches of all areas repeated. If still not located - the Team must discuss and agree the decision to complete the surgical procedure. This must be escalated to both relevant CSU
  0.Management Teams.
• The decision and a description of the item must be documented by the surgeon in the surgical notes.
  It must also be documented on the Accountable Items Record and the Perioperative Care Plan. A DATIX must be completed.
• The Surgeon / Operating Clinician must inform the patient about the event and outcome. This must also be documented in the patient’s surgical notes.

9.3 Microscopic Missing Items

• Microscopic missing item(s), such as fine sutures or fragments of suture needles are to be documented on the Accountable Items Record, the Perioperative Care Plan and in the patient’s Surgical Record. A plain X-Ray should be requested to try and locate the missing item. The clinician may be of the understanding that there may be incidence (very few) where the item is not visualised, however, could not be ruled out as being in situ. Where a decision is made by the Surgeon not to X-Ray the patient, it must be recorded on DATIX and in the patient’s Surgical Record that an X-Ray of the patient was requested by the Perioperative Team but was deemed not helpful by the surgeon.
• This must be escalated to the Team Leader / Deputy Theatre Manager / Matron.

9.4 If an Accountable Item is discovered on the floor during the procedure

• The scrub practitioner must be informed as soon as the item is found.
• A check must be made by the scrub and circulating practitioner of all of the same items on the opened trays, to establish where the item is missing from.
• The information must be documented on the whiteboard including, the name of the item, time found, and checks completed by whom and which tray the item is from.
• This information must also be documented on the appropriate section of the Accountable Items
  Record Sheet.
• Items that are witnessed when dropped onto the floor are written onto the whiteboard
  - but the check of the instrument trays does not need to occur

9.5 Intentional Retention of Surgical Swabs as a pack

• Only X-Ray detectable surgical swabs are to be used if intentionally retained in the operative site.
• A record of any intentionally retained surgical swabs must be documented on the Accountable Items Record and the Perioperative Care Plan, stating the quantity and type of surgical swab(s) retained. The surgeon must document this action in the patient’s surgical record.
• Information on the retained surgical swab(s) must be included in the handover from the scrub practitioner to the PACU staff and then to the ward nurse, prior to transferring the patient back to the ward.
• The patient and / or relatives (if appropriate) must be informed by the Surgeon of the need for the pack(s) and the need to return to the Operating Theatre for removal.
• Patients who are transferred to PACU with intentionally retained swabs must have written and verbal handover between theatre and PACU staff. If PACU remove intentionally retained swabs this must be documented on the Accountable Items Record. If intentionally retained swabs are not removed in PACU there must be written and verbal handover to ward staff.

9.6 Removal of the intentionally retained Surgical Swab (used as a pack)

• When the patient returns to the operating theatre for the removal of the intentionally retained surgical swab(s), the Team (surgeon, scrub and circulating practitioners) identify the size, number and location of the surgical swab(s) from the previous documentation (surgeon’s operative sheet and Accountable Items Record).
• As the surgical swab(s) are removed they are checked for the size, number and that they are intact (including the presence of tape(s) if applicable).
• They must be checked by the scrub and circulating practitioners into a separate swabsafe container.
• If there is a discrepancy between the number and size of retained surgical swabs removed and the previous documentation, an X-Ray of the patient must be taken to ensure there are no retained items.
• Removal of the packs must be documented on the current Accountable Items Record in the pink discrepancies box

Vaginal packs

• Vaginal packs must be x ray detectable
• When a full size vaginal pack is not required it should be trimmed and the excess discarded
• It must be fully documented that the pack has been trimmed, therefore not a complete pack
• It must be documented on the accountable items record and in the care plan
• At sign out, the presence of the pack must be confirmed as an item to be communicated to PACU at handover and that it is clearly documented in the accountable items record and in the care plan.
• There must be a clear verbal handover of the pack between theatre team and PACU
• There must be a clear verbal handover of the pack between PACU team to ward nurse
• The surgeon must document the on-going post op presence of the pack on the operation sheet and whether it is a complete pack or has been cut. It should also state when the vaginal pack has to be removed and by whom.

9.7 On discovering a mistake in any Accountable Items Check

• If during any surgical / interventional procedure a mistake with the accountable Items check is noticed - this must be escalated immediately to the team or above as appropriate. A DATIX must be completed if appropriate.
• All team members must strive to rectify the mistake and escalate accordingly
• All team members must write an account of what happened during the procedure and the accountable items check

9.8 If a Patient is returned to the Operating Theatre / Procedure Room For removal of Unintentional
Retained Items (A Never Event)

• A Datix must be completed for any patient who is returned to the Operating Theatre / Procedure room to have a ‘retained item’ removed and the incident must be escalated immediately as per incident trigger list for never events
• When the retained item has been removed - it must be kept separate from the current accountable items check by placing in a separate swabsafe or receiver (dependent on the item)
• A plain x-ray of the patient must be taken to ensure all items have been removed from the patient
• The incident must be documented in all relevant areas: perioperative care plan, surgical / operation note, and Theatre Register
• All team members must write an account of what was found
• If an item is found during a patient’s secondary procedure (which may be a while after the primary surgery) this must be escalated immediately as a ‘Never Event’, recorded on a DATIX and in the Surgical / operation notes, Perioperative Care plan and Theatre Register.
• A plain x-ray of the patient must be taken to ensure no other items are still retained in the patient - and the x-ray reported on by a Radiologist
• All Team Members involved must write an account of what happened during the procedure as soon as practicable.

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