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Member, Incorrect Surgical Counts Working Group

Posted • Last updated


Open to Fraser – Vancouver Coastal, Patient partners in the Lower Mainland & Fraser Valley

Last updated

Are you interested in promoting patient safety in the operating room? St. Paul’s Hospital is looking for a patient partner to join their working group to review surgery processes/protocols when an incorrect count of sponges, instruments and needles is encountered at the end of a surgery. Would you like to participate in making sure that no objects are retained, whilst at the same time minimizing delays in the operating room, reducing prolonged anesthesia and the need for unnecessary x-rays? If yes, this may be the opportunity for you!

Open to: Patient partners in the Lower Mainland & Fraser Valley

Lead Organization or Department

St Paul’s Hospital; Department of Surgery


A review of St. Paul’s Hospital's patient safety data reveals that the current protocol when there is an incorrect count at the end of a surgery is not followed correctly by all involved health care providers 100% of the time. With patient safety at the forefront of our project, we aim to identify the barriers to following these protocols as it is vital to maintain patient safety (a retained foreign object after surgery should be a “never event”), yet delaying operating room (OR) and prolonging anesthesia times while the incorrect count is investigated can also create sub-optimal care and can negatively impact operating room workflow and efficiency. The patient partner will be asked to attend committee meetings and provide their input, insights and perspective on this very important issue.

Level of Engagement

This opportunity is at the level of collaborate on the spectrum of engagement. The promise to you is that the health care partner will work together with you to formulate solutions and incorporate your advice and recommendations into the decisions to the maximum extent possible.


If you have a strong interest in this work but have not yet completed a PVN orientation and volunteer agreement, are unsure if your experience is a good fit or feel another format of engagement would work better with your availability, please contact the engagement leader directly.


  • 1 vacancy
  • Monthly meetings; in-person attendance required (schedule for meetings to be determined)
  • Location: St Paul’s Hospital, 1081 Burrard Street, Vancouver
  • Six-month commitment required, with possibility of extension


Transit and parking will be reimbursed up to $22/day and mileage up to 60km each direction, as per Providence Health Care reimbursement policy.


In reviewing patient safety data, it came to our attention that there were a significant number of events related to incorrect surgical counts. After exploring this further, it became clear that in approximately 50% of cases, the institution’s protocol to be followed in the event of an incorrect count was not being properly followed by all health care providers on the surgical team. This issue was brought forward to the Surgical Quality Committee and a decision was made to form a working group to complete a process improvement project addressing this issue. The purpose of the project is to evaluate the protocol for incorrect surgical counts in its current state and, by discussion with frontline staff and all stakeholders, do a “deep-dive” into the data surrounding the Patient Safety & Learning System events. We hope to develop a better understanding of why the protocol/policy is not always followed. The working group will then plan to modify the policy so that it supports all surgical services in all situations where the surgical count is incorrect – ultimately patient safety is at the forefront of this work. The working group members include surgeons, anesthetists, OR nurses and OR nursing leadership, radiology technicians, patient quality and safety leaders and a patient partner.

Health Care Partner Contact Information

Karen Estrin
Engagement Leader, Patient and Public Engagement | Lower Mainland & Sunshine Coast

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