PRACTICAL PROJECT 1: FORMULATION OF A STANDARD OPERATING PROCEDURE
Unit: Execution of Perioperative Theatre Administrative Services
Selected Activity: Counting of Instruments and Swabs
Submitted By: Lexy Atieno Emilia
Admission Number: Dtt/L6/1488/09/24
Date of Submission: 23 January 2026
SELECTED ACTIVITY AND JUSTIFICATION
a) Activity Selected: Counting of Instruments and Swabs (Surgical Count)
b) Justification for a Formal SOP:
A formal Standard Operating Procedure (SOP) for counting instruments and swabs is
critically needed for the following reasons:
1. Patient Safety:
The main goal is to prevent retained surgical items (RSIs). These serious, preventable
events can cause infection, re-operation, legal issues, and harm or death to patients. A
consistent process is key to ensuring safety.
2. Risk Mitigation:
3. The fast-paced operating room is prone to human error, interruptions, and
distractions. An SOP standardizes the counting process, reduces variability, and
lessens reliance on memory, which helps manage these risks.
4. Legal and Regulatory Compliance:
Following a documented SOP shows due diligence, provides a legal defense, and
ensures compliance with national healthcare standards (e.g., National Core Standards,
South Africa) and accrediting bodies (e.g., COHSASA).
5. Clarity of Roles and Accountability:
The SOP clearly outlines the responsibilities of each team member (Scrub Nurse,
Circulating Nurse, Surgeon). This promotes shared accountability and removes
ambiguity. 5. Quality Assurance and Audit Trail: It establishes a clear process to
monitor compliance, investigate discrepancies, and support continuous improvement
efforts.
Objective of the Activity:
In order for all surgical instruments, swabs, and other counting instruments such as needles that
can be counted before, during, and after the surgery in an attempt to verify that no instrument has
been left in the patient unintentionally.
Human Resources Required:
• Registered Scrub Nurse (or Scrub Technician
• Registered Circulating Nurse
• Surgeon (with particular responsibility in closing the cavity)
• Anesthetist (conscious of the process, requires stability of the field)
• Theatre Manager/Supervisor (for policy issues and discrepancies)
Materials, Equipment, and Supplies:
• Counted sterile items: Surgical instruments (small and fragile), swabs (raytec,
laparotomy), needles, blades, instrument parts (screws, nuts), vessel loops, peanuts,
kittners
• Non-sterile
• Sheets of count documents (manual or computer-based).
• Permanent markers for labelling.
• Radiopaque and barcoded when feasible.
• X-ray facility (for resolving discrepancies in the count).
Safety and Infection Prevention Risks:
• Retained Surgical Item (RSI): This poses the most severe risk of developing sepsis,
fistula, perforation, and death
• Cross contamination: Handling count sheets or boards with contaminated gloves.
• Process Breakdown: Interruptions, miscommunication, incorrect counts because of poor
technique, incomplete counts of damaged parts.
• Sharps Injuries: When counting needles, blades.
Relevant Policies:
• Legal/Legislative: National Health Act; Occupational Health and Safety Act (OHS Act)
– safe working environment.
• Labour: Scope of Practice for Nursing Professionals (SANC); Theatre staff training and
competency requirements.
• Environmental: Waste segregation policy (Disposal of Contaminated Swabs Post-Count
• Hospital/Institutional: Theatre Safety Policy; Infection Prevention and Control (IPC)
Policy; Adverse Event Reporting Policy; Policy for Correct Site, Procedure, and Patient;
Manual for Expanded Programme for Immunization (EPI) - for serving as a
standardization protocol.
DRAFT - STANDARD OPERATING PROCEDURE (SOP
“OPM” shall mean
Version: 1
Effective Date: Upon Approval
Page: 1 of 5
STANDARD OPERATING PROCEDURE FOR COUNTING OF SURGICAL
INSTRUMENTS, SWABS, AND SHARPS
PURPOSE: To create an accurate and traceable system for counting all-countable surgical
items used in surgical procedures to ensure that there are no Retained Surgical Items (RSIs).
APPLICABLE SCOPE: All perioperative staff (Scrub Nurse, Circulating Nurse, Surgeons,
Anesthetists) participating in various surgeries carried out in any of the operating theaters.
DEFINITIONS & ABBRE
• RSI: Retained Surgical Item
• Initial Count: This is the first count carried out prior to initiating the procedure.
• Closing Count: The count carried out during the closure of a body cavity or deep layer,
and the final skin closure.
• Final Count: This was the confirmed complete and accurate count at the end of the
process.
• Count Sheet: The paper or electronic sheet on which the count number is recorded.
• Circulating Nurse (CN): The unsterile member of the team who records the count.
• Scrub Nurse (SN): This is the sterile personnel responsible for manipulating and
assessing items for counting.
RESPONSIBILITIES:
• Scrub Nurse: Conducts the physical count of sterile equipment audibly; insures that
everything is in sight and distinguishable; notifies team of any broken instruments.
• Circulating Nurse: Logs counts on the counting sheet; listens for and verifies counts;
maintains integrity of counting field; initiates procedure for counts that are not right.
• Surgeon: The count is acknowledged and respected; pauses when closing the cavity for the
closing count; assists in the search when a discrepancy is identified.
Theater Manager, Staff Training for this SOP, Audits for Compliance, Notifies for
Unresolved Discrepancies
REQUIRED MATERIALS/EQUIPMENT:
• Approved count sheets/
• Purpose-built counting area that is cleaned and
• All countable surgical items with radiopaque markers.
LEGAL PROCESS DESCRIPTION
• Pre-procedure or Initial
• Even before the patient arrives, the SN and CN do a preliminary count together.
• The way in which CN opens the products onto the field is methodical. The way in
which the SN counts the items aloud can be visually and
• The number is recorded in the count sheet and repeated verbally by CN.
• The counting is recorded before making any cuts.
Intra-procedure:
All additional items placed in the field are counted as soon as it is opened.
The removed specimens (swabs, blades) are stored in an appropriate container.
Closing Count (Before Cavity Closure):
The SN alerts the team, "Closing count commencing. “The SN and CN conduct an actual count
of all products, including those in the discard container and the mayo stand and back table.
CN compares totals to the running total on the count sheet.
Final Count (At Skin Closure)
The final verification count is carried out.
The CN declares: "Final count correct" only after completing the reconciliation.
After
Both SN and CN sign the count sheet and record it in the patient file.
If false, then go to Discrepant
SAFETY & IPC PRECAUTIONS:
• "No Interruption Zone": It is not allowed to count interruptedly.
• Aseptic Technique: CN does not touch anything that is sterile. SN has maintained sterility
• Sharps Safety: Count needles/blades in a designated tray with caution.
• Containment: Every used countable item shall be contained in the theatre during the final
count and verification.
QUALITY ASSURANCE MEASURES:
• Mandatory double-signature on count sheets.
• Regular random audits of count documentation by the Theatre Manager.
• Annual competency assessment for all the nurses in the perioperative nursing on the count
procedure.
DOCUMENTATION & RECORD KEEPING:
• The original count sheet forms part of the patient's permanent perioperative record.
• Any discrepancy must be documented on an Incident Report form and the count sheet.
REFERENCES:
1. Theatre Safety Policy v3.2
2. South African Nursing Council. (2013). Scope of Practice for Nursing Personnel.
3. Guidelines for Prevention of Retained Surgical Items. (2019). AORN Journal.
APPROVAL PAGE:
Author: ________________________________________________________________
Signature: _______________________________________________________________
Reviewer (Theatre Manager): _____________________________________________
Signature: _______________________________________________________________
Approver (Head of Clinical Services): ______________________________________________
Signature: _______________________________________________________
VALIDATION AND REVIEW REPORT
a) Presentation: The draft SOP was presented to two senior theatre sisters [supervisors] and
three peer theatre nurses during a scheduled staff meeting.
a) Feedback Collection: Done using a structured checklist - see Appendix A. Main feedback:
1. Add a clear "Discrepancy Protocol" flow chart as an appendix.
2. The comparison must be "visual and tactile."
3. Define whose responsibility it is to count broken instrument parts.
4. Following is intra-operative X-ray of the fracture if absolutely necessary.
c) Revisions Summary:
• Added a new section to the SOP titled "
6. DISCREPANCY PROTOCOL" with very explicit steps spelling out the following courses of
action in sequence:
1) Inform Surgeon & stop closure,
2) Field search, kick buckets, floor,
3) Recount,
4) If problem remains, refer Theatre Manager,
5) Consider intra-operative X-ray, and
6) Document
• Step 1.2 revised to "SN counts each item aloud, visually and tactilely."
• Scrub Nurse Responsibilities revised to read: ".and accounts for any broken instrument pieces."
• Appendix A (Feedback Checklist) and Appendix B (Discrepancy Protocol Flowchart) created
and attached.
d) Checklist Attached: As in Appendix A.
MONITORING & EVALUATION (M&E) PLAN
Component Description
1. Compliance Rate: % of procedures with fully and correctly completed
count sheets.
Key Performance 2. Count Discrepancy Rate: Number of discrepancies per 100 procedures.
Indicators (KPIs) 3. RSI Incidence: Number of confirmed retained items (Target: Zero).
4. Training Compliance: % of staff completing annual SOP competency
assessment.
1. Audit Checklist (based on SOP steps) for random case observation.
Data Collection 2. Count Sheet Review from patient records.
Tools 3. Incident Report database for discrepancies and RSIs.
4. Training Register.
* Continuous: Self-monitoring via documentation.
Monitoring
* Weekly: Theatre Manager reviews all discrepancy reports.
Frequency
* Monthly: Random audit of 5% of surgical cases and their documentation.
Quarterly M&E Meeting: Theatre Manager, senior nurses, and a surgeon
Evaluation Method representative review KPI data, audit findings, and incident reports to evaluate
SOP effectiveness and identify trends.
1. Monthly audit summary reported to Theatre Manager.
2. Quarterly M&E report with KPI analysis circulated to all theatre staff and the
Reporting Procedure
Quality Assurance committee.
3. Critical incidents (RSI) reported immediately via the adverse event system.
Component Description
* If discrepancy rate >1%, mandatory refresher training is triggered.
* Feedback from M&E meetings is used to revise the SOP annually or as
Improvement Plan
needed.
* Success (0 RSIs) is reinforced and celebrated in staff meetings.
REFERENCES
Association of perioperative Registered Nurses. (2020). Guidelines for prevention of retained
surgical items. In Guidelines for Perioperative Practice.
South African Government. (2003). National Health Act No. 61 of 2003.
South African Nursing Council. (2013). Scope of Practice for Nursing Personnel. (As amended).
8. APPENDICES
Appendix A: SOP Feedback and Validation Checklist
Appendix B: Count Discrepancy Protocol Flowchart
Appendix C: Sample Count Sheet
Appendix D: Monthly Audit Checklist Template