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?

Type of Count

Initial

Relief

Cavity

Facia/Muscle

Skin

Off the Field

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?

All sharps counted?

Instruments counted for procedure with cavity?

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 alerted of discrepancy?

Radiographs obtained to locate missing item?

Documentation of items counted and by whom?

Timing of counts appropriate for case?

Reconciliation activities and outcomes documented?

Actions taken if discrepancy occurred and outcome documented