The fourFail Points

• Any unlabeled medication or solution on the sterile field, including a cup of saline or water.
• Accepting a medication without verifying it out loud with the circulator.
• Passing a medication to the surgeon without stating its name and strength.
• Drawing up or pouring a second medication before the first one is labeled.
• Accepting a medication the patient is allergic to, or not knowing the allergies.
• Throwing away the original vial or container before the case is over.

The scrub doesn’t give drugs on their own authority, but everything that leaves your hands must pass every right. Know them by heart; instructors ask.

• Right 1PatientConfirmed at the time out: name, date of birth and allergies.
• Right 2DrugMatches the preference card and the surgeon’s order. Read the label; never go by the color or shape of the vial.
• Right 3Dose / strengthThe concentration matches the order: 1% vs 2% lidocaine, 1:100,000 vs 1:200,000 epinephrine.
• Right 4RouteTopical, local infiltration, irrigation or injection. Some drugs are topical only, such as thrombin and 1:1000 epinephrine.
• Right 5TimePassed when the surgeon needs it, and still in date.
• Right 6DocumentationThe circulator records what was given and how much. You report the amounts.
• Right 7ReasonThe drug matches why it’s being used in this case.
• Right 8Right to refuseAny doubt about a drug means stop and clarify before it goes on the field.

1. Prepare firstHave a sterile, empty medicine cup or graduate, or a syringe, ready, with your sterile labels and marker on the back table, before the circulator opens anything.
2. The circulator shows you the labelThey hold the vial or bottle so you can read it. You never take an unverified container.
3. Verify out loud, togetherThe circulator reads the label aloud and you read it back aloud.
   • Drug name
   • Strength / concentration
   • Amount or volume
   • Expiration date
   • Solution is clear: no discoloration, cloudiness or particles
   • Vial intact: nothing cracked or punctured
4. Confirm no allergyTo that drug, from the time out.
5. Transfer aseptically
   • Cup or graduate: the circulator pours slowly without splashing and never reaches over the field. Hold the cup near the table edge. A poured bottle’s lip is contaminated; it isn’t recapped and re-poured.
   • Syringe from a vial: the circulator holds the vial upside down. You draw it up with a large-bore needle (such as 18 gauge) or a transfer device, without touching the vial, then change to the needle the surgeon wants.
   • Vial spike or transfer device: follow its directions. It reduces needle use.
6. Label it immediatelyBefore you set it down or touch anything else.
7. Keep the originalThe circulator keeps the vial or bottle in the room until the end of the case, so the label can be re-checked.

An unlabeled cup is a fail even if it’s “just water.”

• !
  Heparin1 mL can contain 10, 100, 1000, 5000 or 10,000 units. Read the units and the volume aloud, label the strength, keep different strengths in different-sized containers, and say the strength on every pass.
• !
  Epinephrine 1:1000 (1 mg/mL)Topical only, as on pledgets for hemostasis. Injected, it can cause fatal tachycardia and hypertension. Keep it labeled and physically separated from anything going into a syringe.
• !
  Local anesthetic with epinephrineOften has red label printing. Not for fingers, toes, penis or nose tip (end-artery areas).
• !
  Topical thrombinNever injected, and never kept in a syringe on the back table. In a vessel it can cause massive clotting and death.
• !
  Lugol vs MonselBoth brown, both on a cone biopsy table. Monsel on the cervix by mistake can burn the biopsy site. Label both, and say the name on every pass.
• !
  Methylene blue / isosulfan blue / indigo carmineDyes that look alike in a syringe. Label each one.
• !
  Bupivacaine (Marcaine)More cardiotoxic than lidocaine. Never confuse the two; state the drug and percentage.

• Percent
  1% = 10 mg/mL

  Percent = grams per 100 mL. 1% = 1 g/100 mL; 2% = 20 mg/mL.

• Ratio
  1:1000 = 1 mg/mL

  1:100,000 = 0.01 mg/mL (10 mcg/mL); 1:200,000 = 5 mcg/mL.

• Dose
  strength × volume

  10 mL of 1% lidocaine = 100 mg.

• Heparin irrigation
  5 units/mL

  Commonly 5000 units in 1000 mL of saline.

• A contamination you didn’t notice, or noticed and didn’t announce and correct.
• Fingers coming out of the gown cuff during closed gloving.
• Hands dropping below the waist or table level, or tucked into your armpits.
• Reaching over a nonsterile area, or letting a nonsterile person reach over the sterile field.
• Turning your back to the sterile field, or leaving it unattended.
• Using an item without checking its sterility indicators and package integrity.
• Touching a sterile item to a nonsterile surface (the wrapper edge, the table edge, your mask) and keeping it in use.

If in doubt, it’s out.

1. Inspect before openingThe package is intact (no tears, holes, moisture or broken seals), the external chemical indicator has changed, and it’s within its expiration date or event-related sterility.
2. Wrapped table packCenter it on the table. Open the far flap first, then the sides, then the near flap last. Never reach across the opened sterile part.
3. Peel packsPeel the edges back without the contents sliding over the edge. Present the item to the scrub, or flip it onto the field without reaching over.
4. Rigid containersCheck the locks or tamper seals and the external indicator. Lift the lid up and toward you; check the filter or valve is intact and dry.
5. Internal indicatorOnce scrubbed, check it has changed before using anything in the pack or tray. If not, the whole set is not used.
6. Pouring solutionsPour slowly from a few inches up without splashing, pour the entire amount needed, and don’t let the bottle touch the container.

• Hands clasped in front, above the waist and below the shoulders, when you’re not working. Never in the armpits, never folded.
• Face the sterile field at all times. Pass a sterile person back to back or face to face.
• Don’t touch your mask, cap or eyewear. If you do, announce it and change gloves.
• Watch everyone near your field. Speak up if someone nonsterile comes too close or reaches over.
• Draping: hold drapes high and cuff your gloved hands inside. Once placed, a drape is not moved toward the incision. Anything hanging below the table is not sterile.
• Handle as little as possible near the field. Don’t shake drapes or linens.
• The Mayo and back table are sterile only on top. Instruments don’t hang over the edge.

A hidden break is a fail. An announced one usually costs a few points or nothing.

• Glove contaminated or punctured→Announce it, step away, hold the hand out for the circulator to pull the glove off. Reglove by assisted or open gloving (not closed, once the cuff is exposed). Check for an injury.
• Gown contaminated→Announce it. The gown comes off first, then the gloves; put on a new gown and gloves.
• Sleeve touched something→Many programs allow a sterile sleeve cover (stockinette) over the area. Otherwise regown.
• Instrument or item contaminated→Remove it from the field and hand it off. Not used again until reprocessed.
• Drape or field wet or torn→Cover it with a new sterile drape or towel; replace it if it’s soaked through.
• Something dropped→It stays where it is. Tell the circulator; if it’s counted, it stays in the room and in the count.
• Unsure whether it touched→If in doubt, it’s out. Treat it as contaminated.

• Skipping any required count.
• Counting silently, alone, or without the circulator seeing each item.
• Not separating sponges fully, or counting a bundle as “ten” without counting each one.
• Not reporting a discrepancy right away, or saying “correct” when it isn’t.
• Letting a counted item leave the room, or go into the trash, before the final count.
• Adding items during the case without them being counted and recorded.

1. InitialBefore the incision. The baseline everything is compared to.
2. Cavity in a cavityBefore closing one, such as the uterus or bladder.
3. ClosingBefore wound closure begins, usually before the deep layer or peritoneum.
4. FinalAt skin closure or the end of the procedure.
5. ReliefWhenever the scrub or circulator is permanently relieved.
6. Any doubtWhenever a discrepancy is suspected or counted items are added.

Some programs also count at each layer of closure. Follow your rubric.

• ▢SpongesLaps, 4×4 Raytecs, peanuts / Kittners, cottonoids / patties, tonsil sponges. All x-ray detectable in the wound.
• ✦SharpsSuture needles, knife blades, hypodermic needles, electrosurgical tips, safety pins, anything that could cut.
• ✖InstrumentsEvery instrument on the tray count sheet, including separate parts: screws, retractor blades, wing nuts.
• ∞MiscellaneousVessel loops, umbilical tapes, bulldogs, cautery scratch pads, clip bars, trocar parts, per facility policy.

Tap a box to check it off as you practice.

• Together, out loud. The scrub and circulator count at the same time, and both see each item.
• Same order every time. Commonly sponges, then sharps, then instruments; from the field to the Mayo to the back table to items off the field (kick bucket, sponge holder). Use your program’s order.
• Sponges one at a time. Separate each one completely, even in a band of 5 or 10, and check its x-ray detectable element.
• Wrong number in a package? Don’t adjust it. Hand the whole package off; the circulator bags and labels it, and it’s not used or counted in this case.
• Needles by the package. Count by the number printed on the suture pack, verify each needle when opened, and keep used ones in a needle counter or on a magnetic mat. Needle-for-needle exchange.
• Instruments by the sheet. Count against the tray count sheet, including every removable part. Check for broken or missing pieces.
• The circulator writes it down on the count board and in the record as it happens.
• Added items are counted by both of you and written down immediately.
• Nothing counted leaves the room until the final count is reconciled, including trash and linen.
• Report to the surgeon, who acknowledges the result.

Separate every sponge. Count every one.

• Loading or removing a knife blade with your fingers.
• Recapping a needle with two hands.
• Passing a sharp hand to hand without a neutral zone, or without announcing it (if your program requires the neutral zone).
• Leaving sharps loose on the field, the Mayo or the back table, or in a sponge pile.
• Pointing a sharp at yourself or another person, or reaching across a sharp.
• Not reporting a needlestick or cut.

• Common blades: #10, #20, #21 and #22 on a #4 handle; #10, #11, #12 and #15 on a #3 handle (#7 handle for deep work).
• Passing the knife: by the neutral zone if your program requires it. Otherwise blade down, cutting edge away from the surgeon’s palm and fingers, handle placed firmly in their hand, and say “knife.”

• The scrub removes every sharp from the field before the instruments leave the room.
• Remove blades with an instrument or blade remover. Close the needle counter.
• Everything goes into a puncture-resistant, leak-proof, labeled sharps container.

1. Announce it and step away. Remove the glove and reglove sterile.
2. Wash the site with soap and water as soon as you can. Don’t squeeze or scrub it harshly.
3. Report it right away to your instructor or charge nurse and follow the exposure protocol. Post-exposure prophylaxis works best started within hours.
4. Document it. The source patient may be tested per policy.

• Verbalize everything.Instructors grade what they can hear. If you don’t say it, it didn’t happen.
• Own mistakes immediately.Say what happened, fix it, keep going. Freezing or hiding costs more than the mistake.
• Know the why.Be ready to explain the reason behind any step.
• Smooth beats fast.Accuracy first; speed only after you’re accurate.
• Be consistent.Same counts, labels and setup every time, so nothing gets skipped under pressure.
• PPE before you scrub.Eye protection, cap, mask and shoe covers.
• Speak up at the time out.Patient, procedure, site and laterality, allergies, and that every medication is labeled.