Operating Room Instrument Count Audit

Inspection template for auditing operating room instrument counts during initial closing and final counts, including discrepancy identification and resolution.

Case and Count Documentation

• Procedure, room, and date/time documented
  Record the procedure name, operating room number, date, and audit time.
• Circulating nurse and scrub person identified
  Document the personnel responsible for the count.
• Count sheet or electronic count record available at point of use
  Verify the count record is present and accessible during the audit.
• Initial count baseline established before closure
  Confirm the baseline count was completed and documented before wound closure.

Initial Closing Count Verification

• Sponges counted and reconciled
  Verify all sponges in use were counted and match the documented baseline.
• Sharps counted and reconciled
  Verify needles, blades, and other sharps were counted and match the documented baseline.
• Instruments counted and reconciled
  Verify all instruments on the field were counted and match the documented baseline.
• Count performed audibly and jointly by required staff
  Confirm the count was performed verbally and verified by both the scrub person and circulating nurse.
• Any additional items added during the case were documented and counted
  Verify added items such as sutures, blades, or specialty devices were tracked and included in the count.

Final Count Verification

• Final sponge count reconciled
  Confirm the final sponge count matches the expected total.
• Final sharp count reconciled
  Confirm the final sharp count matches the expected total.
• Final instrument count reconciled
  Confirm the final instrument count matches the expected total.
• Wound closure and patient exit held until count reconciliation
  Verify the team did not proceed until the final count was complete and reconciled.
• Count discrepancy, if any, identified before patient left the room
  Confirm any discrepancy was detected and escalated before room exit.

Discrepancy Resolution

• Immediate recount completed by two staff members
  Verify a full recount was performed promptly by the scrub person and circulating nurse.
• Field, back table, trash, linen, and floor searched
  Confirm the search included all likely locations for the missing item.
• Surgeon notified of discrepancy
  Verify the surgeon was informed immediately when the count did not reconcile.
• Resolution documented with item found or variance explained
  Document where the missing item was found or provide the final variance explanation.
• Escalation completed per facility policy if unresolved
  Confirm escalation to charge nurse, supervisor, or risk management occurred when required.

Audit Outcome and Attestation

• Audit outcome
  Select the final audit result.
• Inspector attestation
  Signature confirming the audit was completed and documented accurately.