She developed a strategy that enabled teams to focus more on simple counting and awareness of what they were dealing with, and reduced those incidents to zero, where they remained for 154,000 surgeries.
1. Instead of conducting the baseline sponge and instrument count in a hurried way after the patient is brought into the OR, when the team is distracted by the urgency to get the case started, all surgical implements are counted and set up in advance.
2. The count process takes priority over responding to pages. Surgeons do not interrupt a count.
3. A wall-mounted white board, rather than a paper count sheet held only by the circulating nurse, displays the count of all soft goods like sponges, sharps, and other miscellaneous items in use.
4. When a surgeon tucks a sponge under an organ, the surgeon notifies the scrub tech or the circulating nurse, and that notation goes on the white board.
5. Counts are done by two people, side by side, and neither is doing something else. They visualize and verbalize the count together.
6. Surgical items are organized in the same way in every OR and counted in the same order each time, rather than allowing staff to choose during that case what they wish to count first.