Hundreds of surgical procedures are performed every day in BC.  To help keep patients safe, perioperative nurses perform a “surgical count” in the Operating Room (OR) to prevent the retention of foreign objects such as sponges, sharps and surgical instruments. The task is highly regulated and effective in reducing the potential for patient harm, yet there are times when surgical count discrepancies occur. Understanding why and how this problem happens is critical for improving patient safety and quality of care in this part of our healthcare system.

Until recently, collecting data about surgical count discrepancies in BC PSLS was not easy. Healthcare staff had difficulty finding the correct fields on the Safety Event Report Form, which made reporting cumbersome and time-consuming. And the way data was collected did not allow the issues to be clearly identified, hindering data analysis and limiting the ability to learn and improve. A better and more consistent approach was needed to improve data quality and ease the burden of reporting and follow-up.

OR nurseIn early 2014, BC PSLS Central Office began working with subject matter experts to develop a new speciality report form tailored to surgical count discrepancies. The leadership of Sharon Bisson, Nurse Educator for the St. Paul’s Hospital Operating Room, was key to the project, and perioperative nurses from around the province gave input on the form to ensure it would meet their needs.  The new Surgical Count Discrepancy Report Form was made available to all Health Authorities on August 27, 2014. In this interview, Sharon shares her ideas about quality and patient safety and her vision for better patient care.

You joined the OR team at St. Paul’s in 2013. What was that like for you?

One of the reasons I was grateful to come to Providence Health Care (PHC) was to share in the mission, vision and values of the organization. Providence is committed to excellence in care, compassion, respect, social justice and integrity. These beliefs are on display everywhere at St. Paul’s, and they are visible in the care we provide and the way in which we treat each other.

Soon after I started at St. Paul’s, I identified some issues relating to surgical counts and documentation. I began looking at why this was happening and I learned quite quickly that there was a lot of confusion about safety event reporting in general. Some staff didn’t understand why we had a system like BC PSLS and many didn’t realize it was a provincial tool (not just for PHC). So I began discussing quality and safety with my colleagues and looking at how BC PSLS could help us improve. Those first few sessions really helped our OR staff to see the utility and purpose of a system like this.

Then you shifted your focus to surgical count issues?

Yes. I started to look more closely at the issues we were experiencing at St. Paul’s. I engaged Radiology, the Surgical Program and some related inpatient areas. It was a team effort. We asked ourselves some really key questions: What does our BC PSLS data show? How often is this happening? Why do surgical count discrepancies occur? But it was extremely difficult to “pull” this information out of the system because surgical count discrepancies were “buried.”

There was no consistent way to report these problems. Data was hard to find and there was a lot of narrative, so there was no way to fully understand what was going on without manually reading each patient safety event.

So you wanted to change the way surgical count discrepancies were reported?

Correct. We needed a consistent way to report these problems whether they occurred here at St. Paul’s or in another facility in a different area of the province. We needed better data. We were really excited when we heard a new form was being considered. We knew we could do a lot with it.

We collaborated with other ORs across the province with the intention of giving staff a simpler way to report these problems. We cleaned up the form by eliminating unnecessary questions, using clearer language and streamlining the drop-down menus.

We referred to guidelines published by the Agency for Healthcare Research & Quality (AHRQ) for Surgery and Anesthesia and the Operating Room Nurses Association of Canada (ORNAC). We’re really happy with the result.

How will Reporters benefit?

Surgical Count TrayThe first thing they’ll notice when they go to the BC PSLS Landing Page is the new icon. Our team chose the logo with the “X” because they felt it most accurately represented the concern. When a Reporter clicks on the form they’ll immediately see how much more intuitive it is to complete. We’ve also created mandatory fields that will initiate a clinical action. Some fields bring up additional questions, leading the reporter through the form in a logical way. So, I think staff will really appreciate that additional fields only appear based on your selection, which makes the form shorter and quicker to fill out. I’m hopeful we’ll see an increase in reporting with the new form. Since it’s less time-consuming, staff will be more easily able to report these issues to us.

And Handlers who follow up on safety events…what’s in it for them?

As a Handler who gives regular feedback to Reporters and is engaged in quality improvement initiatives, I know how important the reporting piece is. With accurate reporting we can begin to answer some key questions: Why is this going on, where and how often? It’s hard for leaders to pinpoint the problem and develop solutions if they can’t identify trends.  I also think the new form will eliminate the confusion Reporters had when filling out the old form.

I’m hopeful that some of the human factors, such as communication, that made it hard to “close the loop” will be eliminated. The intention is for reporting and feedback to be normalized parts of best practice.

Quality and patient safety is something you’re passionate about.

Absolutely, we all are. Our team has an hour together every Wednesday and we incorporate Safety Huddles into that time. A lot of our discussion is based around what I’m seeing in the BC PSLS reports. We’ve been doing a lot of education in the OR so the number of events reported in BC PSLS has been going up. That’s good because it shows that we are talking more about things that matter, including identifying “good catches” and celebrating our successes. My commitment to timely feedback is also increasing reporting because staff know that when they enter a safety event into BC PSLS, it’s being looked at and that it’s important. I suspect with the simpler form that reporting will very accurately reflect what’s actually happening in the OR.

This could mean a shift in the culture at St. Paul’s.

continuous improvementYes, I think so. My hope is to get people engaged in conversations about patient safety. To have them feel comfortable speaking up about things they’re seeing in a non-judgemental way, even in a group setting. Last year my perception was that staff were not comfortable discussing their individual safety concerns, but I feel that it has really progressed. Change can sometimes be slow in healthcare, but there have been a lot of positive steps and I think people are at a point where they’re feeling comfortable discussing near misses and inviting conversation from their peers. It can be hard admitting to someone, “This happened to me and it can happen to anyone,” but we’re getting there.

What will be your priorities over the next couple of years?

Our unit doesn’t have much continuity with individual patients because we transfer them immediately following surgery to other post-operative areas. If an adverse event is reported in BC PSLS that is related to the care we provided but discovered many days later, we sometimes don’t receive that feedback. I’d love for the various departments throughout the hospital to work more closely together.

Additionally, we receive patient referrals from all over the province. Right now the communication link between hospitals in different Health Authorities using BC PSLS is very challenging. It would be great to move in a direction where the various hospitals can view patient safety events from anywhere in BC, so as a patient moves from place to place care providers can follow up to ensure continuity of care. I am hopeful that’s coming. It will be a huge improvement to be able to communicate across hospitals and jurisdictions. We’ve come a long way, though. I’m very optimistic about what’s happening in quality and patient safety, here at St. Paul’s and around the province.

Sharon Bisson has been a Nurse Educator with St. Paul’s since 2013. Previously she worked as a staff nurse in the Operating Room at Vancouver General Hospital. For more information about her quality and safety philosophies, please contact her by email at

Surgical Count Discrepancy (Safety Event Report form) – For staff in perioperative or similar settings to report discrepancies in the pre- and post-procedural counts of surgical instruments and supplies (incorrect count, incomplete count, no count).

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