Which department are you completing this survey for?

Name of the employee observed:

select

Patient MRN?

All sponges and soft good counted?

Pocketed sponge system with a contrasting background color used? (Lap Sponges/Raytecs that are off the field)

Type of Count

Initial (Prior to the procedure before patient enters to OR)

Relief

Cavity (Before closure of a cavity or cavity within a cavity)

Closing (When wound closure begins at the deep layer)

Final (When skin closure begins or at the end of a procedure)

Type of relief:

Relief count performed?

Off the field count performed & verified as correct?

Initial count performed prior to patient entering the room?

Miscellaneous items counted?

Refer to Counting of Sponges Sharps Instruments Policy *any items small enough to become an unintentional retained surgical item

All sharps counted?

Were blades, sutures, and any other sealed sharps opened and visualized?

Instruments counted for procedure with cavity?

Including procedures scheduled as "possible open"

Waived Count?

Reason for waived count:

Was an x-ray performed?

Did a count discrepancy occur?

Process followed when there is a count discrepancy?

Surgeon/Team & Radiology alerted of discrepancy?

Radiographs obtained to locate missing item?

Documentation of items counted?

Timing of counts appropriate for case?

Reconciliation activities and outcomes documented?

Actions taken if discrepancy occurred and outcome documented