Running head: AN INTEGRATIVE REVIEW

An Integrative Review

Maria Solivet

Bon Secours Memorial College of Nursing

Nursing Research

I pledge
AN INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review is to evaluate the literature on current surgical

counting procedures that will prevent any retained surgical items (RSIs). This issue is part of

sentinel events or never events in hospitals worldwide. Although, the revolution of modern

technologies and certain surgical policies in placed have made this incident not as prevalent, it is

still happening in todays hospitals. EBSCO Discovery Series and PubMed were the two

databases that were used to research current articles regarding this issue. Keywords such as,

retained surgical items, unintended retention of foreign objects and surgical counting system

were used to yield over 9,000 articles regarding this topic. Only five articles were chosen to

fulfill this integrative review. This review does have limitations such as the researchers

inexperience pertaining to research and lack of time sorting through all the articles that were

yielded to pick the best ones.

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An Integrative Review

Unintended retention of foreign objects after surgery or retained surgical items (RSIs) is

considered a sentinel event or never-event in hospitals worldwide. With appropriate practice and

safety protocols, these incidents should never happen to patients undergoing any type of surgery.

Unfortunately, this is not true and surgical patients and surgical teams are still faced with this

problem today. The aim of this integrative review is to compile pertinent literature that will

provide answers to the researchers PICO question. For surgical patients or surgical team does

the use of a highly reliable and standardized counting system reduce the risk of unintended

retention of foreign objects after surgery? There was an abundance of research regarding

unintended retention of foreign objects after surgery or retained surgical items; but a gap in

literature exists regarding standardized counting system in surgical procedures. The researcher is

passionate about this topic, because personal experience of losing her mother from an infection

caused by a retained surgical swab after a cesarean delivery had caused her to question why it

happened, when it should never have happened.

Design and Search Methods

This research presents an integrative review and focuses on five research articles. The

databases that were used were EBSCO Discovery Series and PubMed. The keywords that were

used specific to the topic in question were, retained surgical items, unintended retention of

foreign objects, unintentional retention of surgical items, surgical counting system, and

prevention of retained surgical items. The search yielded 7,901 articles in EBSCO Discovery

Series and 2,163 articles in PubMed. The researcher limited the number of articles yielded by

selecting, peer-reviewed and articles that were published in 2011-2016. In addition, the
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researcher added the keywords quantitative and qualitative in the search box along with the

other key terms for this topic in order to retrieve quantitative and qualitative studies only, instead

of meta-analysis or literature review articles. Furthermore, the researcher chose articles that

were written in English and that were from academic journals with full-text provided. The five

articles that are included in this review comprised of two quantitative, two qualitative and one

mixed study, that all relate to the PICO question stated.

Findings/Results

The results and findings of the five research articles indicated that in order to reduce the

incidence of retained surgical items (RSIs) and reduce the miscommunication in operating

rooms, a standardized counting policy worldwide must be followed by all surgical staff involved,

and continuing education/team training must be provided for all surgical staff (DLima, Sacks,

Blackman, & Benn, 2014; Edel, 2012; Santana, Rodrigues & Evangelista, 2016; Stawicki, Cook,

Anderson, Chowayou, Cipolla, Ahmed, Coyle, Gracias, Evans, Marchigiani, Adams, Seamon,

Martin, Steinberg, & Moffatt-Bruce, 2014). A summary of the compiled research articles are

located in Table 1. This review was structured based on the following categories: surgical staff

perceptions of count practice, compliance of all staff to count policy and team training and

continuing education on count policy.

Surgical Staff Perceptions of Count Practice

The two qualitative studies found identified the attitudes and opinions of the surgical staff

who are directly involved in implementing surgical counting procedures. One of the study

explored non-technical, organizational and human factors that impact the reliability of swab

count process by analyzing the experiences of a sample of scrub nurses from a large, multi-site
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teaching hospital (DLima, Sacks, Blackman, & Benn, 2014). According to the qualitative

analysis conducted by DLima, Sacks, Blackman and Benn, it was important to explore

sociotechnical processes underlying the retained surgical swabs and the reasons why the swab

count procedure and related surgical protocols fail in practice (2014). There were several

themes that emerged from this study based on the answers from the scrub nurses. The overall

themes that emerged in this qualitative analysis can be summed up by the conflicting priorities

and ambiguous perceptions of responsibility between the scrub nurses and the surgeons (DLima,

Sacks, Blackman, & Benn, 2014). The researcher thought this was an important finding, because

even though the scrub nurses are the ones handing the surgeons the surgical instruments and

doing the count, it is a team approach in which the surgeons must also be aware of what they are

using and putting inside the patient since they are ultimately the ones operating on them.

Similarly, Edel (2012) conducted a quality improvement project at a large city hospital to

analyze the best practices and reduce any variability in count practices. This study included a

review of count practices among nurses and the surgical technologists at the facility (Edel, 2012).

This quality improvement project was conducted, because the author found several variations in

count practices in the different operating room (OR) departments in the same hospital and even

in the same OR and during the same procedure (Edel, 2012). The facilitys OR managers and

OR quality coordinators of three OR departments along with their staff nurses and surgical

technologists identified practices that created variability and addressed each one to create a new

count policy to reduce the risk of retained surgical items (Edel, 2012). The researcher deemed

this was an important concept to explore, because it shows how there can be discrepancies in

counting policies in different OR departments of the same hospital, but even more disturbing in

the same OR department during the same procedure. The study found that the facility needed to
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develop a standardized count practice in each department in order to reduce self-interpretation of

policies (Edel, 2012).

Compliance of All Surgical Staff to Count Policy

In order to enhance patient safety in the operating room, all members of the surgical team

must comply with the count policy in placed by their respective facilities. Two studies showed

that compliance of all staff member to the count policy and procedure are crucial in preventing

errors in the operating rooms (Santana et al., 2016; Smith & Burke, 2014). In the quantitative

study done by Santana, Rodrigues, and do Socorro Nantua Evangelista, the World Health

Organization (WHO) surgical safety checklist can prevent complications, improve

communication and contribute to postsurgical safety culture; hence, there is a need to investigate

the attitudes and opinions of surgical teams regarding safety utilizing the WHO checklist

(2016). In this study, pre and post-interventions surveys were done to analyze the perceptions

of the surgical team members regarding the utilization of the standardized WHO checklist. The

authors used SAQ-OR modified questionnaire to collect their data and it included the following

objectives such as patient safety perception, communication and teamwork, and checklist

implementation (Santana et al., 2016). The questionnaires were then analyzed using SPSS

software and the Mann-Whitney test was used to calculate the differences between the pre and

post-interventions. Their findings showed that 90% of the respondents agreed that the checklist

was easy and quick to use. The staff increased in compliance with policy and procedure and

improved communication thereby preventing errors in the operating room (Santana et al., 2016).

In the mixed study that was done by Smith and Burke, they evaluated the effectiveness of

the standardized swab and instrument count practices in the operating department of a large
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hospital in South East England (2014). The authors were mainly looking at the effectiveness of

the count practice policy in preventing retained surgical items and the staff compliance regarding

said policies. The study was comprised of both qualitative and quantitative data. The

quantitative data consisted of survey mixed with Likert-style and open-ended questions, followed

by the qualitative data which was an observation of 15 surgical procedures (Smith & Burke,

2014). During the observation part of the study, the surgical team was not aware of when they

were being observed and therefore the outcomes were not influenced at all. One of the questions

that were asked in the survey was, do they follow the departments policy for swab and

instrument count and 90% of the respondents answered yes to this question and the other 10%

did not answer the question at all. But, during the observation portion of the study only three out

of the fifteen surgical procedures that the authors observed followed the swab and instrument

count protocol of the department (Smith & Burke, 2014). This is an implication that there are

inconsistencies between compliance of the staff and knowledge of the count practice.

Team Training and Continuing Education on Count Policy

In order to improve compliance among surgical staff members, continuing education and

team training must be provided regarding count policies. There was one study that the researcher

found that historically, retained surgical items (RSIs) can be attributed to team/system errors

thereby emphasizing the importance of team safety training (Stawicki et al., 2014). This was a

quantitative and retrospective study, in which the authors reviewed and analyzed 71 RSI cases

from January 2003 and December 2009. The authors collected data from RSI cases in 7 different

institutions and the cases were categorized by either individual or team/system errors (Stawicki

et al., 2014). The study findings showed that 90% of the RSIs cases that the authors analyzed

were due to team/system errors (Stawicki et al., 2014). This finding is indicative that team
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training and continued education regarding safe count practice must be offered to all surgical

staff members in order to reduce team/system errors.

The other article that emphasized continuing education regarding count practice policy

was the study that was done by Smith and Burke. They recommend that all staff should work in

completing leadership competencies, as to enhance quality of care (Smith & Burke, 2014). By

doing so, there would be less complacency regarding the surgical count practice policy.

Moreover, continued staff appraisal by the clinical supervisors and continued audit of count

practices should be put in place in order to remain compliant with standard policy (Smith &

Burke, 2014). With all these continued staff development and audits in place, will ultimately

improve surgical safety practice and reduce errors, especially retained surgical items.

Discussion/Implications

The results of the research articles discussed in this review exemplified that there is still a

gap in literature that exists regarding improvement and standardization of surgical count

practices. Although, some of the articles gave evidenced in support of the researchers PICO

question of a standardized counting system to reduce the incidence of retained surgical items;

there is still a huge gap regarding what that standard count system is. Most of the articles gave

evidence in the importance of having a standard counting system to enhance surgical patient

safety, but neither of the articles gave details of what that standard system would look like.

Count practice protocols vary greatly among surgical staff due to self-interpretation of the

departments policy (Edel, 2012). This attributed to discrepancies in count practice due to

confusion among team members, because the policy will be followed one way and another will

follow it a different way. This particular study illustrated the importance of having a
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standardized count procedure, so that self-interpretation of policy will be limited and thereby

reduce the possibility of retained surgical items. Creating a standardized count system will also

improve communication among surgical staff members, because there will be less confusion

regarding count practice, thus reducing the errors in operating rooms.

Limitations/Conclusion

This integrative review had several limitations regarding the topic identified. Even

though the topic is widely researched, however the specific factor of standardized count system

was hard to find. Other limitations that the researcher encountered were the five articles

maximum of the assignment. In addition, there were some articles that were over five years old

that might have supported the PICO question better, but due to the time constraint of choosing

articles that were less than five years old limited the researcher of options. Moreover,

delimitation exists due to the researchers limited experience in nursing research and writing an

integrative review.

Findings discussed in this integrative review substantiate the importance of having a

standardized count practice in operating rooms (OR) across the country or at least among the

different OR departments in the same facility. Various factors affect the variability in count

practices among surgical teams that increase errors in OR departments. This was due to different

perceptions of surgical staff members regarding count practice (DLima, Sacks, Blackman, &

Benn, 2014; Edel, 2012). To reduce count discrepancies and enhance patient safety, a standard

count practice must be in place and staff compliance to the policy must be achieved (Santana et

al., 2016; Smith & Burke, 2014). For compliance to be achieved, continuing education must be

provided to all surgical staff members (Smith & Burke, 2014; Stawicki et al., 2016).
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References

DLima, D., Sacks, M., Blackman, W., & Benn, J. (2014). Surgical swab counting: a qualitative

analysis from the perspective of the scrub nurse. Journal of Perioperative

Practice, 24(5), 103111.

Edel, E.M. (2012) Surgical count practice variability and the potential for retained surgical

items, AORN Journal, 95(2), pp. 228238. doi: 10.1016/j.aorn.2011.02.014.

Santana, H.T., Rodrigues, M.C.S. and do Socorro Nantua Evangelista, M. (2016) Surgical

teams attitudes and opinions towards the safety of surgical procedures in public hospitals

in the Brazilian federal district, BMC Research Notes, 9(1). doi: 10.1186/s13104-016-

2078-3.

Smith, Y. and Burke, L. (2014) Swab and instrument count practice: Ways to enhance patient

safety, British Journal of Nursing, 23(11), pp. 590593. doi:

10.12968/bjon.2014.23.11.590.

Stawicki, S.P., Cook, C.H., Anderson, H.L., Chowayou, L., Cipolla, J., Ahmed, H.M., Coyle,

S.M., Gracias, V.H., Evans, D.C., Marchigiani, R., Adams, R.C., Seamon, M.J., Martin,

N.D., Steinberg, S.M. and Moffatt-Bruce, S.D. (2014) Natural history of retained

surgical items supports the need for team training, early recognition, and prompt

retrieval, The American Journal of Surgery, 208(1), pp. 6572. doi:

10.1016/j.amjsurg.2013.09.029.
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Table 1 Qualitative and Quantitative Article Evaluation

First Author Santana (2016) National Health Surveillance Agency, Brazil
(Year)/Qualifications

Background/Problem The studys purpose is to evaluate and analyze the attitudes and opinions regarding surgical safety procedures among operating room
Statement professionals. These surveys were done before and after implementation of a surgical safety checklist.

Conceptual/theoretical Not identified

Framework

Design/Method/Philosophical Cross-sectional study/Quantitative study

Underpinnings

Sample/ Setting/Ethical Study consists of 472 health professionals

Considerations The study was done in three public hospitals in the Central-West region of Brazil, between 2012 and 2014.
Hospital one teaching hospital with a high level of care; 748 bed; 16 ORs; performs 7,267 surgeries/year
Hospital two general hospital; medium to high-risk patients; 299 bed; 10 ORs; performs 2905 surgeries/year
Hospital three district teaching hospital; 226 beds; 5 ORs; performs 3695 surgeries/year
Major Variables Studied (and Operating room professionals
their definition), if Pre-intervention (Period I) before checklist implementation
appropriate Post-intervention (Period II) after checklist implementation

Measurement Tool/Data Attitude and opinion assessment tool about surgical safety, based on SAQ-OR modified questionnaire
Collection Method Questionnaire included patient safety perception, communication and teamwork, checklist implementation
Pre- and post-intervention of the WHO surgical safety checklist
Data Analysis Mann-Whitney test
Online survey builder revised by the researcher
SPSS software, version 11.5
Findings/Discussion 257 pre-intervention/215 post-intervention
Implementation of the checklist increased integrated team effort, greater participation and surgical team situation awareness
Surgical safety checklist can modify personal attitudes thereby improves the patient safety
92.9% of the nursing staff and 100.0% of anesthesiologists found the checklist to be a brief and quick tool
14.0% of the surgeons thought they were extensive and time consuming
Some of the health professionals may be skeptical in their attitudes and opinions towards a checklist due to it will increase their
workload
87.8% (nursing staff and anesthesiologists) thought that the checklist improved communication within the team
Appraisal/Worth to practice Checklist formalizes tasks to be performed without adding tasks to services/Filling time of the checklist is singular and takes 2-3
minutes
Miscommunication is a common cause in never events, which can be prevented through a formalized/standardized checklist
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First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
12
Smith (2014) Endoscopy Unit Service Manager, Croydon Health Services NHS Trust, London
The studys aim was to evaluate the efficiency and standardization of swab and instrument count practices at a large
hospital in South East England.
Not identified
Mixed study both qualitative and quantitative study
Consisted of surveys & questionnaires of the operating room staff (mainly nurses) and the observations of
surgical procedures
For the survey a total of 50 staff in the main OR department and 15 from the day surgery
The second part of the study was an observation of 15 surgical procedures
The study was done in a large hospital NHS Trust in South East England
Operating room professionals
Swab and instrument count practice protocols
Perceptions of operating room professionals
A mix of Likert-style and open-ended questions
Observations of 15 surgical procedures with the staff unaware of when the teams would be observed
SPSS software
Staff was unaware of when they were being observed
In the survey/questionnaire, almost 90% responded that they follow the departments policy for swab and
instrument counting procedures, the remaining 10% did not respond to this question
In the observation part of the study, only three out of the fifteen procedures that were observed followed the
departments swab and instrument count
The key to compliance is staff education, which will then improved the safety and quality of care for the
patients
This article shows that even though the OR departments have a surgical policy regarding count practices,
some of the staff are not complying, but they are documenting that they are
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First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
First Author
13
Stawicki (2014) Doctor of Medicine Department of Surgery, The Ohio State University College of
Medicine, Columbus, OH
The studys aim was to bridge the literature gaps by conducting a secondary analysis of a multicenter study
regarding retained surgical items (RSIs).
Not identified
Quantitative Study
Retrospective study of RSIs
Seven-center retrospective study
A total of 71 RSI occurrences were analyzed
RSI occurrences from seven different institutions
Safety omissions or variances data
7 institutions
Post hoc examination of data from a 7-center retrospective study of RSIs
Procurement of specific event-related information from each site by an investigator, then compiled to a
central location
Data came from: medical records, surgical quality or sentinel even query review, other internal reports
available, presence or absence of pertinent safety protocols
Descriptive statistics results were presented as proportions and central tendencies graphs and tables
Differences were analyzed using chi-square or Fisher exact test, as appropriate
Minitab 16 software was used
In the survey/questionnaire, almost 90% responded that they follow the departments policy for swab and
instrument counting procedures, the remaining 10% did not respond to this question
In the observation part of the study, only three out of the fifteen procedures that were observed followed the
departments swab and instrument count
Most surgical procedures complicated by RSIs were found to involve team and system errors and 2 or more
SOVs emphasizes the importance of team safety training
Prompt recognition of RSI and early treatment are important in reducing morbidity and mortality
Edel (2012) MN, RN, CNOR, CNS Director of Ambulatory Surgery at St. Lukes Episcopal Hospital,
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(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
First Author
14
Houston, Texas
The studys aim was to evaluate the policies and practices and the high degree of count practice variability
among staff members of the same facility, but different OR departments and the potential for retained surgical
items.
Not identified
Qualitative Study
Quality Improvement Project
St. Lukes Episcopal Hospital 46 ORs 3 surgical departments: cardiovascular, thoracic, transplant;
inpatient (i.e. main OR); and ambulatory
Interviewed a total of 120 staff members from the 3 OR departments and labor and delivery department
Registered nurses and surgical technologists from the different OR departments
Count practice protocols
Group interviews discussed the different count practices from each department
No more than 8 staff member in each group interview, so that staff can speak freely and to ensure enough
time for discussions
Objectives eliminating variation in count practices, reinforcing staff member accountability, ensuring open
communication without repercussions, advocating for patients, respecting and adhering to count practice
requirements and eliminating excuses for not following facility count policy
Areas of variation in communication and documentation counts
Obstacles and factors that affect accurate counting
Staff members identified the variations in practice
Staff identified that they were adhering to the existing policy but the extent of practice variability and policy
interpretation was wide
The need of standardization of count practices will strengthen a culture of accountability, improve general
communication, support patient advocacy, renew respect for count policy and procedures and communicate
concerns, problems and variances to coworkers and managers with no repercussions.
Continuing education on count policies and procedures will increase adherence and compliance of staff
members.
DLima MSc Health Psychology, BSc Psychology
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(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
15
The studys aim was to conduct a qualitative analysis from the perspective of scrub nurses in which it explores
the underlying reason behind unintended retained surgical swabs and why the swab count procedure and related
protocols fail in practice.
Sociotechnical framework
Qualitative Study
Sample size of 27 scrub nurses from a large, multi-site teaching hospital
Purposive and included staff from a variety of different grave levels (competency levels)
Scrub nurses with different competency levels
Perceptions on swab count policy
Interviews of the scrub nurses were conducted by a heath psychologist and was reviewed by a multi-
disciplinary research team interviews lasted 20 minutes
Questions were centered around participants views on: current policy for the swab count, personal
responsibility for ensuring that all swabs are accounted for at the end of a procedure, and facts that impact
on a scrub nurses ability to conduct the count efficiently Participants reflected on their experiences
Inductive analysis used grounded theory
Deductive reasoning by social psychological and safety science models
A qualitative template was discussed between the multidisciplinary group and number of iterations were
developed until no new categories of meaning were derived
Reported a range of experiences regarding swab count seven themes emerged as factors that affect the
procedure psychological, human and organizational factors that affect the scrub nurses ability to conduct
the count reliably
Conflicting priorities and ambiguous perceptions of responsibility play a role in the reliability of safe count
practices Ongoing awareness promotion that is tailored to individual surgical roles and multidisciplinary
team training should be addressed