Surgical Education Learners Forum/Perioperative Nursing/Surgical Counting/Psychomotor Skills Practice Instructions

Surgical Counting – Perioperative Nursing (ECSACONM)

Overview

This page provides a psychomotor skills practice guide for surgical counting, developed for perioperative nursing training under ECSACONM (East, Central and Southern Africa College of Nursing). It is intended as a self-directed exercise, outlining the sequential steps, associated learning objectives ("good skills"), common errors, and practical guidance for performing accurate surgical counts throughout a procedure.

To promote efficient use of resources, items such as instruments, gowns, drapes, gloves, and other consumables may be used in an unsterile state for practice purposes. During all skills practice activities, learners should handle and use these items as though they are sterile and intended for patient care, demonstrating correct aseptic technique and adherence to sterile principles throughout the procedure.

NB: The below skills should be practiced with an assistant who plays the role of circulator nurse.

Instruments and Supplies

The same instruments and supplies should be used for practice and examination. The exercise does not require a complete surgical procedure, but the field should contain enough realistic equipment and countable items to require the learner to perform a systematic surgical count.

Furniture and Simulated Operative Field

Operating table or equivalent surface
Drapes to create a simulated operative field
Simulated abdominal operative field or opening where a laparotomy sponge can be placed out of direct view
Mayo stand with sterile cover/drape
Back table with sterile cover/drape
One or more kick buckets or other receptacles normally used for discarded sponges
Sharps container or needle-counting device
Count board, whiteboard, or other visible location where the circulator can record the count
Marker or other method for recording the count

Countable Items

The exact numbers may be adapted to locally available instrument sets, but the standardized practice and examination setup should include:

Laparotomy sponges
Smaller radiopaque gauze/swabs if these are normally counted separately
Suture needles
Scalpel blade(s)
Surgical instruments from a general laparotomy set
6 towel clamps that are to be included in the instrument count
Any additional locally appropriate countable item included in the examination

In an exam situation, the number of each category used in the examination should be known to the examiner but should not be given to the learner before the baseline count.

Personnel

Two people participate in the count:

Learner: performs the scrub nurse role.
Assistant: performs the circulating nurse role and participates in the count.

The observer should be positioned so that the learner's hands, Mayo stand, back table, operative field, kick bucket(s), and count board can be seen whenever possible.

Initial Setup

Before the exercise begins, arrange all countable items in their normal starting locations on the sterile field. Instruments should be organized on the Mayo stand and back table. Sponges and sharps should remain in their appropriate groups or containers.

All 6 towel clamps should initially be visible and available for the baseline instrument count.

The count board should initially be blank.

The learner and assistant will first perform the baseline count. The examiner will then change the setup for the intraoperative/handover count and again for the final pre-closure count as described below.

Practice Instructions

#	Step	Instructions	Good Skills (Learning Objectives)	Common Errors	Guidance
1	Organize Countable Items for the Baseline Count	Before beginning the baseline count, visually inspect the sterile field and arrange countable items so they can be seen and counted reliably. Separate different categories of countable items. Open or expose instruments sufficiently to allow them to be individually identified without compromising the sterile field.	Countable items are visible and arranged in identifiable groups. The learner establishes an orderly field that allows each item to be counted once without searching through piles or obscured items.	Beginning while items are obscured or piled together; mixing categories; leaving countable items where they cannot be seen; rearranging items while simultaneously trying to count them.	Practice preparing the field before saying the first number. Good organization makes the count easier and reduces the chance of counting an item twice or missing it.
2	Perform Baseline Sponge / Soft-Goods Count	Together with the circulator, count each category of sponge or other countable soft good separately. Separate or visibly indicate each item as it is counted. Count aloud so both people can hear and verify the count.	Both people actively participate in a methodical count. Each sponge is visibly accounted for once, the count progresses in an obvious sequence, and both participants agree on the total before moving to the next category.	Counting silently; counting bundles without confirming their contents; counting too rapidly for the second person to verify; losing track of which items have already been counted; combining different sponge categories into one number.	Use a consistent physical pattern such as moving from one side of the group to the other. Your hands and voice should make it obvious to your counting partner which item corresponds to each number.
3	Perform Baseline Sharps Count	Together with the circulator, count each category of sharp, including needles and scalpel blades. Keep each sharp visible and controlled while it is counted and return it immediately to its designated safe location.	Each sharp is individually accounted for while remaining under control. Both members of the team can see or otherwise verify the item being counted and agree on the total.	Loose or obscured sharps; handling needles or blades unnecessarily; counting a packet without establishing how many countable sharps it contains; leaving a sharp unsecured after counting.	Counting should improve sharps accountability rather than create a sharps hazard. Keep sharps contained whenever possible and use the same safe location throughout the exercise.
4	Perform Baseline Instrument Count	Together with the circulator, systematically count the instruments by following an organized sequence across the Mayo stand and back table. Include all 6 towel clamps in the baseline instrument count.	Instruments are counted in a repeatable sequence. Each instrument is visibly identified once, including all 6 towel clamps, and both participants agree on the total.	Randomly moving between instrument groups; skipping instruments; counting an instrument twice; counting instruments too quickly for the second person to verify; omitting the towel clamps.	Develop a fixed pattern for the instrument count, such as counting by instrument group and moving consistently across the table. Use the same pattern every time.
5	Verify and Record the Baseline Count	At completion of the baseline count, verbally confirm each category and total with the circulator. The circulator records the agreed counts on the count board. The learner checks the recorded numbers against the count that was just completed before proceeding.	The learner and circulator verbally agree on each total, the circulator records it, and the learner visibly verifies that the recorded baseline matches the count performed.	Recording an unverified number; moving to the next activity before both people agree; failing to check the count board; allowing a transcription error to remain unnoticed.	Treat recording as part of the count rather than an administrative task performed afterward. Use a simple sequence: count → agree → record → verify.

The assistant changes the field to simulate an operation in progress. The setup should include: one laparotomy sponge legitimately inside the simulated patient; used sponges distributed among designated locations such as kick bucket(s); one sharp present on the sterile field; and 4 of the 6 towel clamps attached to drapes and/or securing tubing or cables. The remaining countable items should be distributed realistically between the Mayo stand, back table, operative field, and designated receptacles.

Phase 2 — Intraoperative / Handover Count
#	Step	Instructions	Good Skills (Learning Objectives)	Common Errors	Guidance
6	Identify the Intraoperative Count Environment	Before counting, the learner visually surveys these locations and prepares to include them in the count.	The learner recognizes that countable items are now distributed across multiple locations and deliberately establishes where each category must be counted before starting.	Counting only what remains on the back table; overlooking the operative field, kick bucket, sharps area, or towel clamps attached to drapes; beginning without surveying the environment.	Before saying the first number, mentally trace the locations an item could have moved to during an operation: patient → operative field → Mayo → back table → receptacles. The exact sequence may vary locally, but it should be consistent.
7	Perform Intraoperative / Handover Sponge Count	With the circulator, methodically count all sponges across their current locations. Include sponges remaining on the sterile field, sponges in kick bucket(s) or other designated receptacles, and the laparotomy sponge known to be inside the simulated patient. Count each item once and verbally reconcile the total with the baseline count.	The learner and circulator account for the sponge inside the simulated patient as well as sponges in all other locations. The final total agrees with the baseline count.	Counting only visible unused sponges; failing to include the sponge inside the patient; overlooking a kick bucket; physically mixing already-counted and uncounted sponges; accepting an incorrect total without reconciliation.	Do not rely on all items being together. Practice following the same location-based search pattern every time so an item legitimately in use is still included in the count.
8	Perform Intraoperative / Handover Sharps Count	Together with the circulator, identify and count all sharps. Include the sharp currently present on the sterile field as well as sharps already secured in the designated sharps location. Maintain control of the exposed sharp throughout the count.	The sharp on the field is visibly identified and included without being lost, duplicated, or handled unsafely. The total reconciles with the established count.	Counting only the sharps container; overlooking the sharp in active use/on the field; picking up or moving an exposed sharp unnecessarily; losing visual control of a sharp during the count.	Ask yourself where a sharp can legitimately be at this moment, rather than assuming every sharp will already be in the sharps container.
9	Perform Intraoperative / Handover Instrument Count	Together with the circulator, count instruments systematically across the field. Include the 4 towel clamps currently attached to drapes/tubing/cables and the remaining 2 towel clamps wherever they are located. Reconcile the instrument total with the baseline count.	All instruments are accounted for despite being distributed around the field. The learner deliberately includes the towel clamps being used on the drapes and obtains the same total established at baseline.	Counting only instruments lying on the tables; overlooking towel clamps attached to drapes; removing towel clamps unnecessarily just to count them; counting an attached clamp twice.	Learn to count instruments where they are when safe to do so. Items being used for a legitimate purpose do not need to be returned to the instrument table simply to be recognized and counted.
10	Verify and Complete the Handover Count	Verbally reconcile each count category with the circulator and with the documented baseline. Confirm that the count is correct before completing the simulated personnel handover.	Both participants agree that all categories reconcile with the baseline, and the learner demonstrates that accountability has transferred without losing knowledge of items currently in use, including the sponge inside the simulated patient.	Declaring the count correct without comparing it with baseline; completing handover while a category remains uncertain; failing to communicate that an item remains inside the patient or otherwise in active use.	At handover, do not communicate only the number. Make sure the incoming team understands important countable items that are currently in use or in unusual locations.

The assistant changes the setup to represent the end of the procedure. Remove the laparotomy sponge from the simulated patient and distribute used countable items in realistic end-of-procedure locations, including kick bucket(s), the Mayo stand, back table, and sharps containment. Towel clamps may remain attached to the drapes.

Phase 3 — Final Pre-Closure Count
#	Step	Instructions	Good Skills (Learning Objectives)	Common Errors	Guidance
11	Survey and Organize All Count Locations for the Final Count	Before beginning the final count, the learner visually surveys all locations and organizes items sufficiently to permit a reliable count.	The learner establishes a deliberate search/counting pattern that includes the operative field, Mayo stand, back table, receptacles, sharps area, and items still attached to the drapes.	Immediately counting the most convenient pile; overlooking receptacles or drapes; assuming that all items have already been returned to the back table; failing to organize mixed items sufficiently to count them reliably.	Treat the final count as a complete accounting of the whole operative environment, not simply a recount of the back table.
12	Perform Final Sponge / Soft-Goods Count	With the circulator, methodically count all sponges and other counted soft goods from every designated location. Separate or visibly identify items as they are counted and compare the resulting totals with the baseline count.	Every sponge is accounted for once, including used sponges in kick bucket(s) or other receptacles. No sponge remains in the simulated patient, and the final total agrees with baseline.	Missing a receptacle; counting a sponge twice; failing to separate counted from uncounted items; assuming an item is present rather than visually accounting for it.	Use the same category order and location sequence practiced during the earlier counts. Consistency is more important than speed.
13	Perform Final Sharps Count and Secure Sharps	Together with the circulator, count all needles, blades, and other counted sharps. Confirm that no loose sharp remains on the operative field. Secure counted sharps in their designated containment and compare totals with the baseline count.	Every sharp is positively accounted for, the total agrees with baseline, and all sharps are controlled and safely contained.	Counting without visually accounting for individual sharps; leaving a loose needle or blade on the field; disposing of a sharp before it has been accounted for; unsafe handling during consolidation.	The final sharps count has two useful outcomes: reconciliation of the count and a field in which sharps are controlled for subsequent breakdown.
14	Perform Final Instrument Count	With the circulator, systematically count all instruments from the Mayo stand, back table, operative field, and other locations. Include all 6 towel clamps, including any clamps that remain attached to drapes or securing tubing/cables. Compare the total with the baseline instrument count.	Every instrument is visibly accounted for once. All 6 towel clamps are included regardless of location, and the instrument total agrees with baseline.	Counting only instruments on the tables; forgetting attached towel clamps; double-counting instruments moved during the count; changing counting sequence partway through.	Follow the same instrument-group and location sequence used during the baseline count whenever possible. Deliberately include instruments that are still performing another function.
15	Reconcile and Verbally Confirm the Final Count	Compare each final count with the documented baseline. The learner and circulator verbally confirm agreement for each category. The circulator records the final count result and the learner verifies the documentation.	Every category is explicitly reconciled. Both people agree on the result, and the learner verifies that the documented result accurately reflects the completed count.	Saying only “the count is correct” without reconciling individual categories; one person counting or verifying alone; failing to compare with baseline; failing to verify documentation.	Finish each category completely: count → compare → agree → record → verify. Do not let completion of the simulated procedure rush the final verification.
16	Respond to a Count Discrepancy	If the assistant announces that one category does not reconcile, do not proceed as though the count were correct. Repeat the count systematically with the circulator, checking the operative field, Mayo stand, back table, kick bucket(s)/receptacles, sharps locations, drapes, floor, and other locations appropriate to the missing item. Notify the surgical team of the unresolved discrepancy and proceed according to local policy.	The learner immediately treats the discrepancy as unresolved, communicates it clearly, and performs an organized recount/search rather than an unsystematic search. The learner does not falsely declare the count correct.	Ignoring the discrepancy; changing the recorded baseline to make the numbers agree; searching randomly; failing to inform the team; declaring the count correct because an item is probably somewhere outside the patient.	Practice discrepancy management by having the assistant occasionally move or conceal one item. Use the same systematic search sequence rather than simply looking wherever you think the missing item is likely to be.

References

Page data
Keywords	surgery, health
SDG	SDG03 Good health and well-being
Authors	Ian-laurel
License	CC-BY-SA-4.0
Organizations	SELF, ECSACONM
Language	English (en)
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Created	July 13, 2026 by 2607:FEA8:3441:6400:9DB7:3F82:7765:2223
Last edit	September 28, 2026 by GSTC
Cite as	"SELF/Perioperative Nursing/Surgical Counting/Psychomotor Skills Practice Instructions". Appropedia. 2026. Retrieved October 3, 2026.
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