The increase use of RISKMAN to report incidents of harm or near misses – this can help the managers collect information to improve patient outcomes and safety by implanting policies and procedures.

At RMH, a photocopy of the count sheet us uploaded on the patient file. From reading the case study, this record keeping system only stays in place for 7 years from the date of last entry for an adult. I would like to see this time frame extended or kept on the patient file indefinitely to allow for court proceedings to take place and come to an outcome if an RSI is found more than 7 years from the surgery date.

On the Count Sheet, ensuring you are writing the name of the surgery on both sides of the sheet as the patient may be coming for multiple surgeries and have intentionally retained packs. This ensures correct and accurate record keeping of each count sheet for each surgery. A count sheet could potentially be co-signed by the surgeon to have a documentation that an accurate count sheet has been completed by all surgical team members.

More Nursing Staff in Theatres can allow for the count sheet to be done with no other distractions or the circulating nurse trying to do multiple tasks at the same time. This can impose a threat of the surgical count being miss counted.

Additionally, it is a good idea to document the marking pen and paper ruler that come with the pack. They have been used often in different general procedures. Including the Ligaclip packets, any small caps that come with all the consumable instruments and the vials of the local anaesthetics are necessary. The reason is that they are usually small in size and not as necessary as consumables we will use immediately. This increases the risk of ignorance.

Human error during the surgical count also contributed to the unintended retention of surgical items in these cases. To reduce the risk of miscounting instruments and consumables, both nurses should count together and aloud to ensure accuracy. Additionally, it is crucial to minimize interruptions during the counting process to guarantee that all items used in the surgery are accounted for and retrieved.

References:

Lujun, Z., Yuan, G., & Wei, W. (2024). Surgical counting interruptions in operating rooms. BMC Nursing, 23, 241. https://doi.org/10.1186/s12912-024-01912-1

Warwick, V. R., Gillespie, B. M., McMurray, A., & Clark-Burg, K. G. (2021). Undertaking the surgical count: An observational study. Journal of Perioperative Nursing, 34(3), Article 1. https://doi.org/10.26550/2209-1092.1089

Royal Melbourne Hospital. (2023). Surgical Count. https://app.prompt.org.au/search

Weprin, S., Crocerossa, F., Meyer, D. et al. Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review. Patient Saf Surg 15, 24 (2021). https://doi.org/10.1186/s13037-021-00297-3

Kay factors that contributed for the sentinel event:

Incorrect count: During the operation, two nurses (a scrub nurse and a scout nurse were responsible for performing the surgical count. Their count was incorrect, and the discrepancy went unnoticed, resulting in a sponge being left in the patient’s body.

Breakdown in communication: There appeared to be minimal communication between nurses and surgeons to confirm final counts. Without an enforced cross-check or formal team sign-off, the opportunity to catch the error before closure was missed.

Reference:

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery. Journal of Law and Medicine, 26(4), 841–848.

Nursing and Midwifery Board of Australia (NMBA). (2016). Registered nurse standards for practice. Nursing and Midwifery Board Ahpra. https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx

Perioperative Nursing Standards (ACORN): Guidelines requiring a two-person count (typically scrub and circulating nurse), documented and confirmed before surgical closure.

Education and training programs focusing on non-technical skills such as communication, situational awareness, and teamwork.

Australian College of Operating Room Nurses (ACORN). (2023). The New ACORN Standards 2023 Professional Practice Standardy for Perioperative Nurses (PPSPN) for Individuals. www.acorn.org.au/acornstandards

World Health Organization. (2009). Surgical Safety Checklist. https://www.who.int/docs/default-source/patient-safety/9789241598590-eng-checklist.pdf

Depending on the surgery and size of the wound, I believe we should count:

⁃            Huck towels

⁃            Liga and hemo clips

⁃            K wires

⁃            Tie packets

⁃            Syringes (specifically 1, 3 and 5ml)

⁃            Markers

⁃            Rulers

⁃            Port cleaners

All the listed items above are small, used frequently, and can easily be lost inside the body cavity.

Another new modern technology is ORLocate Counting and Detection system. This machine allows the ability to count multiple consumables before, during and after the procedure. It is also able to detect items within the patient also (Fogle, 2023). These new technologies could be implemented into our practices to reduce risks of RSI's.

References:

Fogle, L. (2023, February 13). What are Retained Surgical Items? | Knowledge Center. Www.steris.com. https://www.steris.com/healthcare/knowledge-center/surgical-equipment/retained-surgical-items

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• The ligaclip packets

• Marking pens - including their lids

• Rulers

• Hypodermic caps

These are frequently used consumables that are small but can be lost within the body cavity.

References:

Association of PeriOperative Registered Nurses. (2024). Understanding retained surgical items (RSI): Importance, prevention, and AORN guidelines. https://www.aorn.org/article/understanding-retained-surgical-items-%28rsi%29--importance--prevention--and-aorn-guidelines

Snape, A. J., Duff, J., Oya, Gumuskaya, Inder, K., & Hutton, A. (2022). Strategies to prevent inadvertent retained surgical items: An integrative review. Journal of Perioperative Nursing, 35(4), e11-17 https://doi.org/10.26550/2209-1092.1196 

Reference:

Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services, (2024), https://psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology

Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services, (2021), https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough

The ACORN Standards (2023) highlighted the importance of recording intentionally retained objects; that is, the documentation has to be clear and accurate to maximise the team’s awareness of such items. Failure to do so led to severe patient harm or the case of the sentinel event mentioned above.

Therefore, it is reasonable to believe that the initial surgical team involved in James Stirling McKinlay did not accurately document the number of intentionally retained objects, thus creating a miscommunication between different surgical teams.

References:

Australian College of Perioperative Nurses. (2023). 2023 Standards for Safe and Quality Care in the Perioperative Environment (SSQCPE) for Organisations.

 Cockburn, T., Davis, J., & Osborne, S. (2019). Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery. Journal of law and medicine, 26(4), 841-848.

The common factors can be attributed to ineffective communication among the various members present in the operating room during the procedure. The first two cases highlight miscommunication between the nursing team and the surgical team regarding the incorrect count. This communication is one of the actions expected by ACORN (2023), which also recommends additional steps: recounting and conducting a search for the missing item with the surgical team. The nursing team’s failure to follow these protocols demonstrates their inability to follow guidelines and negligence.

Additionally, in cases involving intentionally retained surgical items, inaccurate or incomplete documentation further reflects communication breakdowns. Accurate documentation of surgical counts enables other healthcare professionals to clearly understand a patient’s surgical history and plan appropriate treatment, thus greatly enforced by the World Health Organisation (2009). The staff involved in documenting the intentionally retained objects failed to follow strict guidelines and demonstrated negligence by doing so.

References:

Australian College of Perioperative Nurses. (2023). 2023 Standards for Safe and Quality Care in the Perioperative Environment (SSQCPE) for Organisations.

World Health Organisation. (2009). WHO Guidelines for safe surgery: safe surgery saves lives.

Recommendations from Susmallian et al. (2022) include but are not limited to minimising distractions while performing surgical counts, such as noise, music, and interruptions and having a consistent approach to performing surgical counts. At the RMH, the standard approach when counting consumable items is to count items that are off the surgical field, moving towards the sterile “dirty bowl”, to the scrub nurse working table, then the surgical field. Having this approach assists both the scrub and scout nurses involved a systematic approach and avoids the same item being counted twice or missed.

Further, the RMH Policy Surgical Count (Royal Melbourne Hospital, 2023) details the requirements that the two nurses need to follow when performing a surgical count. They include, but are not limited to, requiring the two nurses to count the items together and out loud, and whenever discrepancies or interruptions occur, they would recommence the count. Counting the items out loud can help the two nurses identify and agree on the same number of items together. Further, informing the surgical team when the final count is conducted can reduce the interruptions the scrub nurse might face while performing the count.  

References:

Royal Melbourne Hospital. (2023). Surgical Count. In Perioperative Department (Ed.), (10 ed.). Prompt: Royal Melbourne Hospital.

Susmallian, S., Barnea, R., Azaria, B., & Szyper-Kravitz, M. (2022). Addressing the important error of missing surgical items in an operated patient. Israel Journal of Health Policy Research, 11(1), 19. https://doi.org/10.1186/s13584-022-00530-z

Here are some recommendations for items that should be included on RMH count sheets:

·         Skin marker

·         Paper ruler – especially when they are trimmed or cut into smaller pieces

·         Hypodermic caps

·         Paediatric feeding tubes used in microsurgery – some nurses would count this item, but the majority would not

·         Ligaclip packaging

References:

Australian College of Perioperative Nurses. (2023). 2023 Standards for Safe and Quality Care in the Perioperative Environment (SSQCPE) for Organisations.

·      Incorrect Surgical Count – Scrub/Scout nurses performed an inaccurate sponge count, indicating an error in documentation that all sponges had been retrieved and removed from the patient.

·      Heavy Reliance on Manual Counting Processes – The surgical count process heavily relies on human performance of manual counting without technological processes (eg: radiofrequency detection/Xray).

·      Communication Failure – The surgeon relied on confirmation from nursing staff that the count was correct, illustrating a breakdown in shared accountability and cross-checking to ensure that there were no further retained objects kept within the patient’s body.

·      Ambiguity in Accountability – Legal disputes and “grey areas” surrounding the issue of “Who is responsible” regarding an incorrect count resulting in a retained surgical sponge could be blamed primarily with the surgeon or the nursing staff. This highlights that there is an unclear governance of perioperative safety roles which led to a sentinel event in this case.

·      Counting errors – Miscounts, omitted items, failure to reconcile discrepancies.

·      Over-reliance on human memory and routine practice

·      Inadequate documentation – Missing or incomplete count records.

·      Poor communication – Not enough attention brought to intentionally retained objects during handovers and patient transfers between hospitals.

·      Delayed discovery – Items not found for long periods of times, sometimes years after surgery, further impacting patient harm and legal complexity.

·      Absence of redundancy systems – Including radiological checks or detection technologies.

Prevention Strategies:

·      Mandatory standardised counting protocols with escalation requirements for unresolved discrepancies (Beukes, 2016).

·      Clear and timely documentation of all items used, removed, or intentionally retained (Freitas et al., 2016).

·      Improved communication during intra-op to post-op handover by utilising ISBAR framework as this has been proven to decrease adverse patient events (Kitney et al., 2018)

Beukes, R. D. (2016). Knowledge of surgical counting practices of operating room nurses in Provincial Hospitals in the Cape Metropole (Doctoral dissertation, Stellenbosch: Stellenbosch University).

Kitney, P., Bramley, D., Tam, R., & Simons, K. (2018). Perioperative handover using ISBAR at two sites: A quality improvement project. Journal of Perioperative Nursing, 31(4), 17-25.

Freitas, P. S., Silveira, R. C. D. C. P., Clark, A. M., & Galvão, C. M. (2016). Surgical count process for prevention of retained surgical items: an integrative review. Journal of clinical nursing, 25(13-14), 1835-1847.

-              ACORN Standards: Emphasises a shared responsibility for surgical counts and requires documentation of counts before, during, and after procedures.

-              NSQHS: Identifies RSIs as sentinel events which require mandatory reporting and root cause analysis.

-              WHO: Reinforces team communication, pause points, and verification before wound closure.

·      Hospital-based protocols (Warwik et al., 2021):

-              Standardised count sheets used consistently across all theatres and surgeries/procedures.

-              Escalation pathways if counts are incorrect (i.e: at RMH, mandatory X-ray prior to closure + RiskMan)

-              Policies requiring retention documentation when items are intentionally left with clear alerts documented on patient files.

·      Technological interventions (Sirihorachai et al., 2022):

-              Radiofrequency identification sponges

-              Barcoded surgical instruments

-              Intraoperative imaging for high-risk procedures

Australian College of Perioperative Nurses. (2024). Standards for Perioperative Nursing in Australia.

Australian Commission on Safety and Quality in Health Care. (2021). National safety and quality health service standards.

World Health Organisation. (2019). Safe Surgery. Www.who.int; World Health Organisation

Warwick, V. R., Gillespie, B. M., McMurray, A., & Clark-Burg, K. G. (2021). Undertaking the surgical count: An observational study. Journal of Perioperative Nursing.

Sirihorachai, R., Saylor, K. M., & Manojlovich, M. (2022). Interventions for the prevention of retained surgical items: a systematic review. World journal of surgery.

·      Explicit documentation of intentionally retained items which not only includes quantity and location but also includes reason and planned removal timeframe.

·      Surgeon verification or sign-off which confirms multidisciplinary confirmation prior to closure. This may help with emphasising a shared responsibility for ensuring correct surgical counts.

·      Time-stamped counts on both the count sheet and EMR with emphasis on ensuring a count is completed as each “layer” is closed.

·      Ultimately, any items, especially small miscallenous items including small caps, marking pens, clip packets, hypodermic caps, etc, that are opened and utilised during the surgery are at risk of being accidentally retained, therefore, should be added to the count sheet.

Sirihorachai, R., Saylor, K. M., & Manojlovich, M. (2022). Interventions for the prevention of retained surgical items: a systematic review. World journal of surgery.

Agrawal, A. (2012). Counting matters: lessons from the root cause analysis of a retained surgical item. The Joint Commission Journal on Quality and Patient Safety, 38(12), 566-AP1.

This case demonstrated major flaws in the systems and processes in place at the time, as it was not standard practice to maintain permanent count sheets or formal documentation of surgical counts. Needle counts were recorded on a whiteboard, meaning there was no permanent record of the count, and increasing the risk of counts being altered, erased, or lost. There were also no clinical notes documenting Mrs Ives’ procedures, further highlighting the extent of the documentation failures.

References:

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained surgical items: lessons from Australian case law of items unintentionally left behind in patients after surgery. Journal of Law and Medicine, 26(4), 841-848. PMID: 31682362.

• Staff negligence and/or unintentional human errors, generally in combination with system and process failures, such as the counting processes within the perioperative systems 

• Inaccurate or lack of documentation, as well as a lack of follow-up systems  

• Poor communication – whether it was between team members or handover between facilities 

• Delayed recognition and discovery of harm – these RSIs were discovered after long periods, generally years after the original surgery, whereby harm had already occurred to the patients, leading to prolonged patient suffering and complicating both clinical management and legal accountability. 

  
  

Additionally, although surgical counts are now standard practice, these cases have demonstrated that counts alone are insufficient safeguards, as errors still occurred due to miscounts, reliance on verbal confirmation, or lack of independent verification 

These sentinel events may have been prevented through: 

• Ensuring accuracy of counts through making sure that all consumables are sighted by both the scrub and scout nurses (both every count that is done), and speaking up to the surgeons if there are any discrepancies, as well as making a clear note of items that have been verbally accounted for but not yet sighted. 

• Clear communication during and regarding counts with all relevant persons, as well as during handovers using ISBAR 

• Fostering a culture of safety and transparency through encouraging reporting, reflection, and learning from near misses and adverse events 

• Introducing measures such as imaging post-procedures (e.g. using the c-arm) to reduce sole reliance on manual counts, which could help to mitigate human error 

References:

ECRI Institute. (2016). Prevention of retained surgical items: Strategies for perioperative teams. ECRI.

Gibbs, V. C., Coakley, F. D., & Reines, H. D. (2007). Preventable errors in the operating room: Retained foreign bodies after surgery—Part I. Current Problems in Surgery, 44(5), 281–337. https://doi.org/10.1067/j.cpsurg.2007.03.001

World Health Organization. (2009). WHO guidelines for safe surgery: Safe surgery saves lives. World Health Organization. https://www.who.int

One key strategy is the use of the WHO Surgical Safety Checklist and structured time-outs. The use of checklists aids in improving communication, confirms count status, and enhances shared situational awareness, thereby reducing preventable sentinel events.

Another measure is the implementation of standardised surgical count protocols, with international and national standards, such as those from the WHO, ACORN, and AORN, which mandate counts at key procedural stages to detect missing items early and prevent RSIs.

In addition, Radio Frequency Identification (RFID) and barcode systems, as well as sponge-tracking technologies provide an additional layer of safety, particularly in high-risk or emergency surgeries where manual counts may be compromised.

Other methods that have been shown to reduce such events include clear leadership and escalation pathways to ensure discrepancies are addressed in a timely manner, as well as fostering a culture that promotes speaking up for safety by reducing hierarchical barriers and encouraging assertive communication, enabling staff to escalate concerns and therefore contribute to prevention of RSIs. 

References: 

Australian College of Operating Room Nurses. (2023). ACORN standards for perioperative nursing. https://www.acorn.org.au/standards 

Cochran, K. (2022). Guidelines in practice: Prevention of unintentionally retained surgical items. AORN Journal, 116(5), 427–440. https://doi.org/10.1002/aorn.13804

Greenberg, C. C., Diaz-Flores, R., Lipsitz, S. R., Regenbogen, S. E., Mulholland, L., Mearn, F., & Gawande, A. A. (2008). Bar-coding surgical sponges to improve safety: A randomized controlled trial. Annals of Surgery, 247(4), 612–616. https://doi.org/10.1097/SLA 

World Health Organization. (2009). WHO surgical safety checklist and implementation manual. https://www.who.int/publications/i/item/9789241598590 

In particular, I think this should include: 

• Rulers – these are often cut into much smaller pieces during procedures, and therefore has a possibly high chance of becoming lost in patients – I believe these should be counted in the same way that backgrounds are counted.  

• Ligaclip cartridges – these are seemingly, more often than not, kept on the scrub nurse’s sterile field rather than handed directly to the surgeon or placed on the surgical field, however, including them in the count would also be beneficial as it helps to provide an additional safety measure and improve accountability. 

• Surgical huck towels – these should be counted in the same way that surgical packs are required to be counted, as they are also used within the operative field and carry a similar risk of being unintentionally retained. 

• Small caps – such as pen caps or hypodermic caps as these items are small and easily overlooked. These could be included under a “caps” section on the count sheet. 

• Items that aren't readily on the count sheet but are already often added on manually – such as drill bits, burrs, throat packs, among others.

It may also be beneficial to have a poster/guide within theatres (similar to the ones for dressings) that inidicates which items are included in each count category, to reduce any ambiguity around what does or doesn't need to be counted, and support consistent counting practices.

References: 

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery, Journal of Law and Medicine, 26 (4), pp. 841-848. 

Goldberg, J. L., & Feldman, D. L. (2012). Implementing AORN Recommended Practices for Prevention of Retained Surgical Items. AORN Journal, 95(2), 205–219. https://doi.org/10.1016/j.aorn.2011.11.010 

References: 

Snape, A., Duff, J., Gumuskaya, O., Inder, K., & Hutton, A. (2022). Strategies to prevent inadvertent retained surgical items: An integrative review. Journal of Perioperative Nursing, 35(4). https://doi.org/10.26550/2209-1092.1196 

World Health Organization. World Alliance for Patient Safety. (2009). WHO guidelines for safe surgery 2009: Safe surgery saves lives. 

References: 

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery, Journal of Law and Medicine, 26 (4), pp. 841-848. 

Goldberg, J. L., & Feldman, D. L. (2012). Implementing AORN Recommended Practices for Prevention of Retained Surgical Items. AORN Journal, 95(2), 205–219. https://doi.org/10.1016/j.aorn.2011.11.010 

Key factors contributing to this sentinel event included intraoperative failure of swab/pack counting procedures, which allowed the pack to remain undetected before wound closure. Surgical counting processes failed to detect that a pack had not been removed before wound closure, indicating breakdown in standard counting procedures and checking routines. According to the Coroner’s report, it was documented at Launceston General Hospital that “six small packs and one large pack were left in situ” (Magistrates Court of Tasmania, Coroners Court, 2013), however only six were removed, with the final pack not being removed for many days.

Postoperatively, a chest X-ray on 6 June 2012 clearly showed the retained pack, but radiologists and the surgical team failed to recognise or act on this abnormality due to poor communication and lack of a robust escalation process.

System gaps, such as inadequate verification protocols and fragmented handoffs between theatre, radiology, and clinical teams, delayed intervention and enabled infection to develop fatally.

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery. Journal of Law and Medicine, 26(2), 458–475.

McKinlay, James Stirling (Coronial Findings), Magistrates Court of Tasmania, Coroners Court, 23 May 2013, 2013 TASCD 142.

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery. Journal of Law and Medicine, 26(2), 458–475.

Osborne, S. R., Cockburn, T., Davis, J., & Hutchinson, A. (2021). Exploring risk, antecedents and human costs of living with a retained surgical item: A narrative synthesis of Australian case law 1981–2018. Journal of Perioperative Nursing, 34(4), e-159–e-163. https://doi.org/10.26550/2209-2790.1167

In Australia, the use of standardised count sheets is best practice and a part of hospital policy. Guidelines for standardised count sheets are governed by the Australian College of Perioperative Nurses (ACORN). They aim to track all accountable items and thus present retained foreign objects in the patient. ACORN-aligned count sheets must list accountable items and be completed at three stages—pre-procedure, cavity closure, and before the patient leaves theatre—and signed by the instrument and circulating nurse.

Another standard of care is the implementation of the WHO Guidelines for Safe Surgery (2009). This report outlines a whole range of objectives and recommendations for universal protocols in the perioperative space. One such standard is the WHO Surgical Safety Checklist which was designed to provide best practice guidelines to decrease errors and adverse events, and increase teamwork and communication in surgery (World Health Organisation, 2009). It confirms critical information in three phases throughout the surgical journey; before anaesthesia (Sign-In), before incision (Time-Out), and before the patient leaves the OR (Sign-Out).

In Victoria, health services are encouraged to report, and undertake reviews of, sentinel events to help identify factors which contribute to adverse outcomes. As per Safer Care Victoria (2022), sentinel event reviews utilise root cause analysis to recommend and inform improved future patient outcomes. These reviews are most effective when undertaken with a diverse team to assess and manage risk factors and improve patient/family engagement in decision making (Safer Care Victoria, 2022).

Australian College of Perioperative Nurses. (2020). Instrument Tracking [PDF]. https://www.acorn.org.au/client_images/2451499.pdf

Patra, K. P., & De Jesus, O. (2023, March 29). Sentinel event. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK564388/

Safer Care Victoria. (2022). Sentinel event annual report 2020–21: Supporting patient safety — Learning from sentinel events [PDF]. https://www.safercare.vic.gov.au/sites/default/files/2022-03/Sentinel%20Event%20Annual%20Report%202020-21.pdf

World Health Organization. (2009). WHO guidelines for safe surgery: Safe surgery saves lives [PDF]. https://iris.who.int/server/api/core/bitstreams/c2ea24bb-10f7-48e4-8f63-55932e817ddc/content

This case highlighted systemic failures rather than individual error, which allowed the retained packs to remain unrecognised.

- Intentionally retained item in high risk emergency context: multiple surgical packs left inside Pt to control bleeding during emergency surgery

- Inadequate documentation of retained items: packs weren’t clearly or consistently documented

- Failed to communicate during transfer of care: retained packs were not effectively handed over

- No additional safety measures: no post op imaging post emergency abdominal surgery to confirm presence or locations of retained packs

Failures in communication, documentation and surgical count + human factors and system pressures

> Inaccurate or incomplete surgical counts — discrepancies not recognised or not escalated prior to wound closure

> Counting errors influenced by interruptions, fatigue, distraction, cognitive overload (Warwick et al., 2021)

> Poor communication between nursing / surgical team , during clinical handover or inter facility transfer

> Inadequate or inconsistent documentation limited continuity of care and delayed detection of retained items (Cockburn et al., 2019)

What could’ve prevented the sentinel events?:

> Strict adherence to standardised counting protocols, eg. two person audible counts, minimising interruptions and mandatory escalation of unresolved discrepancies (ACORN, 2023)

> close-loop communication / structured handover (ISBAR), to support accurate information transfer (Kitney et al., 2018)

> Layered safety safeguards, post operative imaging, technology assisted detection systems in high risk situations to reduce reliance on human memory (Greenberg et al., 2008; Weprin et al., 2021)

Standardised surgical count

• two-nurse out loud count at key stages of the operation

• Counts clearly documented, interruptions require count to restart (ACORN, 2023; Warwick et al., 2021)

Clear escalation when counts incorrect

• immediate escalation of discrepancy and resolved prior to wound closure — pausing procedure until addressed (ACORN, 2023)

Effective communication/structured handover

• closed-loop communication so team can confirm and hear critical information

• Communication tools (ISBAR) during transfer of care to communicate counts and any retained items (Kitney et al., 2018)

Accurate documentation

• surgical counts, discrepancies and intentionally retained items clearly and consistently documented (ACORN, 2023)

Additional safety measures

• Technologies like barcoding, radio frequency tracking and magnetic retrievers to reduce human error when counting (Greenberg et al., 2008; Weprin et al., 2021)

Small miscellaneous items account for a proportion of RSI incidents and are often missed because they’re not routinely counted for. (Romano & Gibbs, 2024)

It could be argued items included in the count could be:

-skin markers + caps

-hypodermic caps

-rulers

-paediatric feeding tubes

-rubber bands

-port cleaners

-ligaclips / hemp clips

-k wires

-wound drain trocars

International Federation of Perioperative Nurses (2019). IFPN GUIDELINE For Surgical Counts. https://www.ifpn.world/application/files/1715/7951/7011/1002__Surgical__Count__.pdf

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery. Journal of Law and Medicine, 26(4), 841–848.

Association of PeriOperative Registered Nurses. (2024). Understanding retained surgical items (RSI): Importance, prevention, and AORN guidelines. https://www.aorn.org/article/understanding-retained-surgical-items-%28rsi%29--importance--prevention--and-aorn-guidelines

Nursing and Midwifery Board of Australia (NMBA). (2016). Registered nurse standards for practice. Nursing and Midwifery Board Ahpra. https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx

World Health Organisation. (2009). WHO Guidelines for safe surgery: safe surgery saves lives.

Goldberg, J. L., & Feldman, D. L. (2012). Implementing AORN Recommended Practices for Prevention of Retained Surgical Items. AORN Journal, 95(2), 205–219. https://doi.org/10.1016/j.aorn.2011.11.010 

Royal Melbourne Hospital. (2023). Surgical Count. https://app.prompt.org.au/search

World Health Organization. (2009). Surgical Safety Checklist. https://www.who.int/docs/default-source/patient-safety/9789241598590-eng-checklist.pdf

Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services, (2021), https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough

Goldberg, J. L., & Feldman, D. L. (2012). Implementing AORN Recommended Practices for Prevention of Retained Surgical Items. AORN Journal, 95(2), 205–219. https://doi.org/10.1016/j.aorn.2011.11.010 

References:

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained surgical items: lessons from Australian case law of items unintentionally left behind in patients after surgery. Journal of Law and Medicine, 26(4), 841-848. PMID: 31682362.

Another common factor in all cases is poor communication. Inadequate communication occurred in theatre between nurses and surgeons, when counting, and when handing over patients to other facilities (Cockburn et al., 2019). Closed loop communication, and standardised ISBAR handover can help improve communication and prevent missed information (Kitney at al., 2020)

References:

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery. Journal of Law and Medicine, 26(4), 841–848.

Goldberg, J. L., & Feldman, D. L. (2012). Implementing AORN Recommended Practices for Prevention of Retained Surgical Items. AORN Journal, 95(2), 205–219. https://doi.org/10.1016/j.aorn.2011.11.010 

Kitney, P., Tam, R., Bramley, D., & Simons, K. (2020). Handover using ISBAR principles in two perioperative sites – a quality improvement project. Journal of Perioperative Nursing, 33(4), 38–45, s12–s13. https://doi.org/10.26550/2209-1092.1094

References:

Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services, (2024), https://psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology

In order to reduce risk of sentinel events, the WHO (2009) recommends a surgical safety checklist at various stages of the surgery. The example checklist provided by WHO could be expanded to include counts to prevent incidences of RSI.

References:

Australian College of Perioperative Nurses. (2023). Standards for safe and quality care in the perioperative environment. ACORN.

Royal Melbourne Hospital. (2023). Surgical Count. In Perioperative Department (Ed.), (10 ed.). Prompt: Royal Melbourne Hospital.

World Health Organization. (2009). WHO surgical safety checklist and implementation manual. https://www.who.int/publications/i/item/9789241598590 

In Case 6, where a drain tube was discovered to have been retained in a patient’s abdomen after 10 years, a couple of key factors could have potentially led to this event occurring, and thus, the subsequent painful outcomes (Pennington, 2024).

1.      Long procedure duration.

2.      Starting the procedure after-hours, such as at night.

3.      Multiple surgical teams are simultaneously operating, and therefore multiple instruments and body cavities are being opened.

4.      Background music or other distractions during critical surgical points.

5.      Not securely anchoring the drain to the skin, which could have broken off and migrated into the patient.

6.      Not thoroughly completing surgical, interim, and final counts.

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained Surgical Items: Lessons from Australian Case Law of Items Unintentionally Left Behind in Patients after Surgery. J Law Med, 26(4), 841-848.

a.      As identified in the study, the common factors are poor counting and documenting of consumable items. For example, in case five, despite the whiteboard count of the needles, it was not formally documented.

b.      There are many demonstrations of poor communication and documentation amongst all the cases presented. When counts were performed, they weren’t properly documented, nor were intentionally retained objects clearly documented.

c.      Not sharing accountability for accountable items in the operating room. That is, these cases indicate confusion among perioperative staff as to who is responsible for performing and documenting the counts.

d.      A combination of systematic and human errors, including non-permanent staff, inconsistent counting and documenting protocols, potential staffing fatigue, distractions, and poor safeguarding measures.

What could have prevented the sentinel events:

a.      Standardising the surgical counting procedures and documenting process so that even when there are non-permanent or temporary staff, the counting and documenting processes are still consistent (Gomes et al., 2023).

b.      Using x-ray or other technology to examine and identify any retained surgical items (Susmallian et al., 2026).

c.      Making sure that all personnel in the theatre, particularly the surgeons and perioperative nurses, understand that the surgical counts are a shared responsibility and should collaboratively make sure that all items are accounted for, that it is clearly documented, and that any discrepancies are immediately escalated (View of Undertaking the Surgical Count: An Observational Study, 2025).

d.      Minimising all potential distractions in the operating rooms, including music, phone calls, and non-case relevant conversations (Nasri et al., 2023).

Gomes, E. T., Albuquerque É, L. M. S., Pereira, A. C. M., & Püschel, V. A. A. (2023). Surgical counting: design of implementation and maintenance of a standardized evidence-based procedure. Rev Bras Enferm, 76(1), e20220144. https://doi.org/10.1590/0034-7167-2022-0144

Nasri, B. N., Mitchell, J. D., Jackson, C., Nakamoto, K., Guglielmi, C., & Jones, D. B. (2023). Distractions in the operating room: a survey of the healthcare team. Surg Endosc, 37(3), 2316-2325. https://doi.org/10.1007/s00464-022-09553-8

Susmallian, S., Folv, E., & Szyper-Kravitz, M. (2026). Assessing the diagnostic value of radiographs for retained surgical items: a cautionary analysis. British Journal of Radiology, 99(1177), 150-156. https://doi.org/10.1093/bjr/tqaf241

View of Undertaking the surgical count: An observational study. (2025). Acorn.org.au. https://journal.acorn.org.au/index.php/jpn/article/view/184/143

a.      Making sure that all perioperative nursing staff are educated about the count sheets and can demonstrate how to document properly (Qualey, 2023). Moreover, education should ensure that all nurses are performing counts in a consistent manner, where differences in the way that counts are performed can increase the risk of errors and thus missed consumable and non-consumable items being accounted for. Additionally, ACORN standards recommend that items remain in their original packaging to maintain a systematic approach for counting as another safeguard against counting discrepancies and errors (View of Undertaking the Surgical Count: An Observational Study, 2025).

b.      According to the Australian Open Disclosure Framework (n.d.), if sentinel or adverse events ensue, discussions should involve the consumers/affected patients as they can provide a different perspective about what factors within the healthcare system might not be as identifiable by healthcare personnel. These consumer contributions can help contribute to action plans that prevent future adverse outcomes from taking place.

c.      As demonstrated within RMH, optimising technology such as electronic medical systems, and surgical checklists (e.g., Timeout) with automatic prompting are great safeguards to ensure all key up-to-date patient information is checked. Other useful technological reporting systems include RiskMan, which can help to analyse adverse events and identify patterns and underlying causes. This can help to inform policy and changes in perioperative practise (Kumah, 2025).

d.      The pressures in the operating room from the surgeons and anaesthetic teams to quickly finish the procedure and accelerate the theatre turnover time, such as by removing the drapes before the final count is finished, can lead to errors in surgical counts and thus, the potential for missed consumables or instruments being left inside a patient (View of Undertaking the Surgical Count: An Observational Study, 2025).

e.      Perioperative nurses should be counting out aloud so that all theatres personal are aware to withhold from disrupting them to prevent a counting error (View of Undertaking the Surgical Count: An Observational Study, 2025).

f.        As well as performing an x-ray to check for any retained consumable or non-consumable items, Gibbs & Romano (2025), recommend having a “time out” period where surgical and nursing teams can survey the patient and exposed body cavities as well as instrument trays to check that no items have been retained in the patient, or, to acknowledge that there are still some items or instruments that are currently deliberately within the patient.

g.       Finally, fostering an environment where staff feel comfortable and safe to speak up to voice their safety concerns is another measure that could prevent the occurrence of sentinel events (Seo & Lee, 2024).

Australian Open Disclosure Framework. (n.d.). https://www.safetyandquality.gov.au/sites/default/files/resources/attachments/Australian-Open-Disclosure-Framework-Feb-2014.pdf

Gibbs, V., & Romano, P. (2025). Retained Surgical Items: Causation and Prevention. Retained Surgical Items: Causation and Prevention. https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention

Kumah, A. (2025). Poor quality care in healthcare settings: an overlooked epidemic [Review]. Frontiers in Public Health, Volume 13 - 2025. https://doi.org/10.3389/fpubh.2025.1504172

Qualey, R. (2023). Documenting Perioperative Care in the Electronic Health Record. AORN Journal, 118(4), 261-266. https://doi.org/https://doi.org/10.1002/aorn.14010

Seo, J. K., & Lee, S. E. (2024). Improving Patient Safety and Care Quality Through a "Speaking-Up" Climate: The Mediating Role of Situation Monitoring. Risk Manag Healthc Policy, 17, 2035-2043. https://doi.org/10.2147/rmhp.S471043

View of Undertaking the surgical count: An observational study. (2025). Acorn.org.au. https://journal.acorn.org.au/index.php/jpn/article/view/184/143

·       Syringes

·       Surgical skin markers

·       Plastic rulers

·       Contrast, e.g., such as a small piece of coloured glove that is used during microscopic surgeries to help the surgeons visualise the arteries and veins

·       Huck towels

·       Liga-clip cartridges

·       Throat packs

·       Cannula caps

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained Surgical Items: Lessons from Australian Case Law of Items Unintentionally Left Behind in Patients after Surgery. J Law Med, 26(4), 841-848.  

View of Undertaking the surgical count: An observational study. (2025). Acorn.org.au. https://journal.acorn.org.au/index.php/jpn/article/view/184/143

1. Reliance on manual counting processes:

The instrument and circulating nurse who were responsible for the surgical counts counted incorrectly. By solely depending on this manual counting process without further safeguards such as utilising X-Ray confirmation, this resulted in the discrepancy between the number of sponges opened at the start of the procedure and what was retrieved at the end of the procedure to go undetected.

2. Poor communication

There was no indication that the instrument and circulating nurse had a common understanding of the number of packs that had been placed into the abdominal cavity during the procedure and when the sponges had all been removed from the abdominal cavity. Usually the instrument nurse would verbalise this to the circulating nurse who will make note of when and how many sponges has been placed and removed from the cavity on the whiteboard as a visual reminder to the entire surgical team. This would ensure that all the abdominal sponges have been removed from the patient's abdomen prior to closure.

There was also a breakdown in communication between the surgeons and the nurses who both strongly rely on each other to be accountable of the number of sponges on the sterile field, in the cavities and sponges that have been retrieved.

3. Ambiguous Roles and Responsibilities

Whilst the surgeon is primarily responsible for the packing and retrieval of the sponge from the abdominal cavity, the nurses are primarily responsible for ensuring that all the consumables and instruments have been retrieved from the patient and the sterile field at the conclusion of the surgery. This resulted in a point of contention between the surgeon and the nurses as to which party was to be accountable for the negligence. Ultimately, the failure of both parties to diligently attend to their respective roles and responsibility in ensuring patient safety resulted in patient harm.

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery. Journal of Law and Medicine, 26(4), 841-848.

• Ambiguity towards responsibility of ensuring that there is no retained objects from the procedure

• Poor documentation and communication between the theatre staff

• Failure to follow established guidelines and policies.

In addition, a range of human factors and systemic pressures could have precipitated these sentinel events. These include fatigue, hierarchical barriers to speaking up and being listened to, complacency in the normalisation of deviance and external distractions such as music and multi-tasking (Saver, 2022).

Even though the surgical count is the most widely used and cost-effective strategy recommended by the ACORN Standards for preventing RSIs, it remains a fallible system.  RSIs may still occur with a presumed correct surgical count, with data suggesting that this occurred in up to 62 to 88% of RSIs (Snape et al., 2022).

Some preventative measures include:

• Reducing distractions to increase accuracy of the surgical count. This can be done by ensuring that the noise levels in the operating theatre are kept to a minimum, such as music, phone calls, and conversations. Instrument and circulating nurses should also not be told to perform multiple tasks or interrupted during the count (Weprin et al., 2021).

• Utilising closed loop communication with everyone in the operating theatre (Weprin et al., 2021).

• Minimising intimidation and hierarchical barriers to staff members speaking up and advocating for patient safety through supportive escalation frameworks and positive team culture (Wright et al., 2024)

• Utilising X-Ray and other imaging and radiofrequency techniques to identify potential RSIs in conjunction with existing surgical count procedures (Snape et al., 2022).

Saver, C. (2022). Addressing the Role of Human Factors in the Retention of Surgical Items. AORN Journal, 116(2), 118-125. https://doi.org/10.1002/aorn.13748

Snape, A. J., Duff, J., Gumuskaya, O., Inder, K., & Hutton, A. (2022). Strategies to prevent inadvertent retained surgical items: An integrative review. Journal of Perioperative Nursing, 35(4), 11-17. https://doi.org/10.26550/2209-1092.1196

Weprin, S., Crocerossa, F., Meyer, D., Maddra, K., Valancy, D., Osardu, R., Kang, H. S., Moore, R. H., Carbonara, U., Kim, F. J., & Autorino, R. (2021). Risk factors and preventative strategies for unintentionally retained surgical sharps: a systematic review. Patient Safety in Surgery, 15(24), 1-10. https://doi.org/10.1186/s13037-021-00297-3

Wright, M. I., Kernen, K., & Kouevi, D. (2024). The Art of Speaking Up: Supporting a Culture of Safety in the OR. AORN Journal, 120(3), 134-142. http://doi.org/10.1002/aorn.14202

In addition, it specifies the expected practice when it comes to handing over, complex set ups and counting away to list a few examples. Most importantly, it details the specific roles and responsibility of the instrument and circulating nurse when there is a discrepancy in the surgical count and the specific steps that need to be taken. (The Royal Melbourne Hospital, 2026)

Nurses should also undergo a robust education in perioperative safety that will ensure their competency in performing safe surgical counts and other practices. This is particularly relevant to novices and new staff, and should be supported in their transition to speciality by the education and management teams. Existing staff should also receive regular training and refreshers into surgical safety expectations to avoid complacency and the normalisation of deviant, non-evidence based practice (Mahoney et al., 2025)

The Royal Melbourne Hospital. (2026). Surgical Count. https://app.prompt.org.au/search

Mahoney, K., Hammerling, S., Chapman, L., & Tucker, J. (2025). Supporting novice nurses in perioperative nursing: A case study of an educational intervention. Australian Journal of Advanced Nursing, 42(4), 41-47. https://doi.org/10.37464/2025.424.2057

• Just as insertion and removal of throat packs are documented in the count sheet, the insertion and removal of packs/ raytecs/ other retainable objects placed in cavities should be documented on the count sheet, not just the whiteboard, where there will be no permanent legal evidence.

• Cut drain tubes - Although the cut length is routinely measured by the instrument nurse, it has the potential of getting retained in the patient if it is not removed promptly from the surgical field.

• Although hypodermics are counted, it does not specifically mention the caps, which are often removed by the surgeons over the operating field. Without careful attention to the actions of the surgeons and where the caps are returned to, they can be easily lost in the operating field and unintentionally retained in the body cavity.

• For a similar reason, marking pens and its caps should be counted.

• Other items include, rubber bands, ligaclip applicator cartridges, stapler cartridges, infant feeding tubes, and cut rulers are all items on the instrument nurse's set up and could always have the potential of becoming an unintentionally retained surgical item.

- The scrub nurse and scout nurse performed an incorrect sponge count where the number of sponges opened did not match the number retrieved. This was then recorded as correct, directly contributing to the unintentional retained surgical item (RSI)

2. Communication failures regarding count accuracy

- Information on the sponge count was communicated inaccurately.

- Effective communication between surgeons and nurses is essential when surgical counts are required.

- Nurses are required to notify the surgeon of correct/incorrect counts

3. Failure to identify the retained sponge before the wound closure

- For major procedures requiring multiple layers to be closed, it is required to do multiple counts to ensure no RSI’s. Multiple counts could also have allowed the team to identify discrepancies in previous counts prior to closing.

4. Distractions during count

- music, interruptions from other members of the operating team, and multi-tasking may have led to incorrect count or documentation of the sponges during the procedure.

5. Inadequate system to detect and prevent retained surgical items, like X-rays

- The counting process was either not performed correctly, or discrepancies were not identified and resolved

- No imaging performed to check for RSI post procedure

References

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery. Journal of Law and Medicine, 26(4), 841-848.

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- There are strict ACORN standards for scrub scout procedures. This includes ensuring that counts are performed at all required stages (before incision, during closure, and at the final count). Additional counts are required in various circumstances. Additionally, two staff members are required to independently verify counts.

- utilising structured counting checklists and reliable documentation modes such as paper count sheets.  

- documenting temporarily RIS when in situ and when removed, including the times throughout the procedure

Communication failures

- Communication from the surgical team to the nursing team when temporarily utilising RIS so that the nursing team can appropriately document this.

- speaking up during incorrect & correct counts in a timely manner before wound closure

- close looped communication

Shared responsibility and accountability issues

- Establishing that RSI is a shared responsibility amongst surgeons, nurses and the organisation

- Clearly defining responsibilities can promote a team-based approach to patient safety.

- ensuring all staff understand their duty of care to ensure accountability in preventing RSI

System and process failures

- implement regular staff education and competency assessments for count procedures

- audits of preoperative practices

- creating a safe culture where staff can escalate concerns

Delayed discovery & Absence of safeguard systems

- Most of these cases involved delayed discovery of RIS, highlighting failure in post-operative vigilance and early recognition of harm.

- reliance on a single safeguard (manual counting) without backup systems

- Availability to technologies like imaging, when there are post op complications without a clear cause or a high index of suspicion for RSI, can allow for early detection

References

Australian College of Perioperative Nurses. (2024).

Standards for Perioperative Nursing in Australia.

Cockburn, T., Davis, J., & Osborne, S. (2019). Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery. Journal of Law and Medicine, 26(4), 841-848.

Goldberg, J. L., & Feldman, D. L. (2012). Implementing AORN

Recommended Practices for Prevention of Retained Surgical Items. AORN Journal, 95(2), 205-219. https://doi.org/10.1016/jaorn.201

1.11.010

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- standardised counting procedures

- two-person verification during counts

- defined responsibilities for the theatre team

NSQHS

- national safety standards for all Australian healthcare services

- highlighting standards 3, 5, 6 to reduce the risk of sentinel events in the operating theatre

World Health Organisation

- surgical safety checklist including sign in, time out & sign out phases

- team communication

- ensuring no critical steps are missed due to human error

Hospital policies and protocols

- documentation of intentionally retained objects

- count sheet & EMR documentation following the above standards

- education sessions

- audits

- competencies

- incident reporting

- culture that fosters speaking up and advocating for patient safety

- escalation pathways (safety C.O.D.E)

- adjunct technology (RFID tracking systems)

References

Australian College of Perioperative Nurses. (2024).

Standards for Perioperative Nursing in Australia.

Australian Commission on Safety and Quality in Health Care. (2021).

National safety and quality health service standards.

World Health Organisation. (2019). Safe Surgery. Www.who.int; World Health Organisation

Cece

Reference
Australian College of Perioperative Nurses. (2023). 2023 Standards for Safe and Quality Care in the Perioperative Environment (SSQCPE) for Organisations.

Cece

In Ives v Australian Capital Territory, surgical counts were recorded on a whiteboard rather than a permanent record, representing inadequate documentation practices (Cockburn et al., 2019). Accurate documentation supports communication, continuity of care, and accountability within healthcare (Mubarack et al., 2025). The absence of a permanent count record limited the investigation of the retained needle and contributed to the sentinel event.

Failure of surgical safety procedures

A failure of surgical safety procedures also contributed to this sentinel event. Surgical counts are designed to account for all instruments and consumables and to reduce the risk of retained surgical items (Gomes et al., 2023). Despite a count being completed, a straight needle remained in the patient's abdomen, indicating that the counting process failed to identify the missing item before wound closure.

Ineffective communication and collaboration

A breakdown in communication within the multidisciplinary team further contributed to the sentinel event. Effective communication is essential for identifying and escalating count discrepancies (WHO, 2009). In this case, the incorrect count was not recognised or escalated, preventing further action to locate the missing needle before wound closure.

Communication was a common contributing factor across the sentinel events, as ineffective communication is a recognised cause of adverse surgical outcomes (Van Dalen, Swinkles, & Schijven, 2022). In several cases, critical information was not communicated or appropriately escalated, resulting in missed opportunities to prevent patient harm. The use of closed-loop communication could reduce these risks by ensuring information is clearly delivered, acknowledged, and confirmed among team members (Van Dalen, Swinkles, & Schijven, 2022).

Incorrect documentation

Incorrect documentation was another common factor contributing to sentinel events. Accurate documentation supports communication, continuity of care, and patient safety (Akbari, Aarabi, & Bahrami, 2025). When records are incomplete or inaccurate, critical information may be overlooked, increasing the risk of adverse events. Maintaining accurate and timely documentation can therefore reduce preventable patient harm (Akbari, Aarabi, & Bahrami, 2025).

Roles and responsibilities in the operating theatre

Failure to fulfil roles and responsibilities within the operating theatre also contributed to sentinel events. The intraoperative environment is highly complex and relies on all members of the multidisciplinary team to perform their designated duties effectively to ensure patient safety (Chellam & Arulappan, 2023). Improved accountability, vigilance, and adherence to professional responsibilities can reduce the risk of preventable adverse events (Chellam & Arulappan, 2023).

World Health Organization. (n.d.). Safe surgery: Tool and resources. World Health Organization. https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery/tool-and-resources 

National Safety and Quality Health Service Standards. (2026). The 8 NSQHS Standards. National Safety and Quality Health Service Standards. https://www.safetyandquality.gov.au/national-standards/nsqhs-standards 

Australian College Of Registered Nurses (ACORN). (2026). Standards for Perioperative Nursing in Australia. https://www.acorn.org.au/standards  

• One key factor that may have contributed to the incorrect tally is the presence of individual human factors such as fatigue, distraction, time pressure, and a lack of adherence to counting protocols and procedures (Mahdood et al., 2023). Human factors such as these can contribute to miscounts, however every effort should be made to minimise their impact on patient safety.

• Within the case, the surgeons demonstrated an over-reliance on the nurses’ count without undertaking their own adequate checking process. In this specific case, this would have involved performing a thorough exploration of the surgical wound or cavity for any retained items prior to wound closure (Susmallian et al., 2022).

• It is also evident that there was significant communication failure within the surgical team, which remains one of the leading causes of medical errors. The nurses incorrectly informed the surgeons that all sponges had been accounted for, and although other factors may have contributed to the inaccurate count, the communication of this false information ultimately resulted in the wound being closed while a sponge remained inside the patient (Chee & Tan, 2025).

Furthermore, this sentinel event highlights a failure in shared accountability within the operating theatre, as the prevention of retained surgical items is a collective responsibility requiring effective teamwork and collaboration between surgeons and nursing staff (Cochran, 2022). 

REFERENCES

Chee, D., & Tan, T. K. (2025). Patient safety in the operating theatre: An ongoing endeavour. Proceedings of Singapore Healthcare, 34. https://doi.org/10.1177/20101058251342344

Cochran, K. (2022). Guidelines in practice: Prevention of unintentionally retained surgical items. AORN Journal, 116(5), 427–440. https://doi.org/10.1002/aorn.13804

Mahdood, B., Bastami, M., Jalal, S. B., Merajikhah, A., & Imani, B. (2023). Contributing factors affecting the counting error in the operating room: a qualitative study. Avicenna Journal of Care and Health in Operating Room, 1(2), 61–70. https://doi.org/10.34172/ajchor.26

Susmallian, S., Barnea, R., Azaria, B., & Szyper-Kravitz, M. (2022). Addressing the important error of missing surgical items in an operated patient. Israel Journal of Health Policy Research, 11(1), 19. https://doi.org/10.1186/s13584-022-00530-z

• Present within all of the cases mentioned throughout the article is a failure in the surgical counting process which resulted in items being unintentionally retained in the individuals bodies after their surgery. Whether that be due to a miscount, incorrect documentation, or not sufficiently monitoring and keeping track of what is going in and coming out. Although all cases were not in the most recent times, regardless of when the incidences took place, there were counting processes in place that ultimately failed.

• Prevention of this failure is linked directly to adherence to sufficient and standardised counting protocols within all theatre operations. As outlined by the Association of periOperative Registered Nurses [AORN] (2016), both the scrub and circulating nurse play key roles and have key responsibilities to ensure a safe counting process, some key factors including: viewing all items being counted, documenting all countable items being placed inside a body cavity in a visible location so that all can see, maintaining an organised sterile field and keeping track of those items both on the field and in the patient.

Poor communication and teamwork

• Within all of the cases, there was ineffective communication among members of the Periop team involved in surgery as well as during transfer of care. As well at this, there was a complete lack of shared responsibility and accountability for patient safety, demonstrated through a lack of teamwork between disciplines (nursing and surgeons) and the wider healthcare system (transferring care of pt).

• Recognising that surgical counts/surgical safety although performed primarily by nurses, is a shared responsibility that involves teamwork and open, clear and concise communication is critical to preventing these sentinel events from occurring. The AORN surgical count guidelines emphasise this - highlighting that every team member involved with a patients surgery including both nurses and surgeons have a role in ensuring correct counts and taking appropriate and thorough action to prevent RSI’s (Swartz, 2024).

Over reliance on manual counting process

• Within the cases, there was an over reliance solely on the manual surgical count without taking other measures to ensure sufficient action has been taken to ensure nothing has been left behind in pt eg. Surgeon performing thorough check of cavity prior to closure demonstrates thorough patient safety.

• The counting process relies heavily on individual performance and human factors such as fatigue, distraction, time pressure and work load can all contribute to mistakes occurring. In some cases when the count is deemed ‘correct’ however items still remain, no attempt to retrieve retained objects is made as it is believed none exist. To address this, alternative options such as automated counting and detection systems like radio frequency sponges are an option (Koek, 2020).

REFERENCES

AORN. (2016). Guideline at a glance: retained surgical items. AORN Journal, 104(5), 474–477. https://doi.org/10.1016/s0001-2092(16)30704-9

Koek, A. Y. (2020). Retained surgical sponge presenting four decades later as a rapidly growing soft tissue mass. Case Reports in Surgery, 2020, 1–3. https://doi.org/10.1155/2020/1230173

Swartz, Z. (2024, August 30). Prevention of Retained Surgical Instruments: AORN’s Surgical Count Guidelines. Aorn.org. https://www.aorn.org/article/understanding-retained-surgical-items-(rsi)--importance--prevention--and-aorn-guidelines

The case of Elliot v Bickerstaff followed key factors that may have contributed to the retained surgical item (RSI) that was discovered after the perioperative period.  

The manual and human process of surgical counting does not guarantee a correct initial or final count (Sirihorachai et al., 2021). Under the assumption that the surgical count was correct, the scrub and the scout nurse involved in the Elliot v Bickerstaff case informed the surgeon that all countable items including gauze sponges were retrieved and accounted for prior to wound closure. The key factor in the RSI event being that the nurses conducted an incorrect surgical count believing they were correct.

Another key contributing factor to the RSI was a potential lack of effective communication. As per Cockburn et al. (2019), it is not the sole responsibility of one person in preventing RSI events, for example, the surgeon leaving a surgical sponge in the wound and closing. Rather, ensuring all countable items are retrieved before closure is reliant on the effective and accurate communication of the entire surgical team, especially the scrub and scout nurse (Sirihorachai et al., 2021).

Cockburn, T., Davis, J., & Osbourne, S. (2019). Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery. Journal of Law and Medicine, 26(4), 841–848.

Sirihorachai, R., Saylor, K. M., & Manojlovich, M. (2021). Interventions for the Prevention of Retained Surgical Items: A Systematic Review. 46(2), 370–381. https://doi.org/10.1007/s00268-021-06370-3

A retained surgical item (RSI) left unintentionally inside of a patient following an operative or invasive procedure, is a serious but preventable medical error and sentinel event that has the potential to cause significant patient harm.(Fencl, 2016).

Perioperative Registered Nurses (RNs) play a critical role in the prevention of RSIs. The updated AORN Guideline for Prevention of Retained Surgical Items provides evidence-based guidance to support a consistent, multidisciplinary approach to RSI prevention across the perioperative team (Fencl, 2016).

Key recommendations from the AORN Guideline for Prevention of Retained Surgical Items include fostering shared team accountability for RSI prevention, minimizing noise, distractions, and interruptions during surgical counts, standardising counting processes for all procedures, identifying with vigilance and promptly resolving count discrepancies, and participating in performance improvement initiatives to reduce the risk of RSIs (Fencl, 2016).

1.        As each of the sentinel events presented in the article involved incorrect confirmation of surgical count accuracy, there may not have been an environment conducive of a correct surgical count. An environment free of excessive noise, distractions, interruptions and involving a standardised manual counting process may assist in preventing RSI events by promoting correct surgical counts.

2.        Each sentinel event disclosed in the article involved a team of medical professionals, where blame was typically placed solely on one person, that being the primary surgeon. The smooth and safe provision of surgical care involves multiple people working cohesively and cooperatively in a team. The onus of an RSI event is thus placed on the team collectively, whereby the entire team must work together to prevent such events and improve upon patient safety and outcomes.

3.        Members of the surgical teams involved in the RSI events may have lacked participation in professional development days involving maintaining and improving their skills and knowledge in accurate surgical counts and communication. Risk reduction may be achieved with greater ease with scrub/scout nurses and surgeons partaking in mandatory and regular refresher courses for RSI awareness and prevention.

4.        These RSI events may have occurred due to lack of attention to detail and double checking of counting and documentation. To be certain that a surgical count is correct, one must double check and confirm numbers with a second healthcare professional, including counting items twice in a row and reading over documentation to ensure accuracy and to provide ample opportunities to identify and correct any errors that may have occurred during in the counting process.

Fencl, J. L. (2016). Guideline Implementation: Prevention of Retained Surgical Items. AORN Journal, 104(1), 37–48.

https://doi.org/10.1016/j.aorn.2016.05.005  

- Failure to detect and remove the straight needle before wound closure

According to Weprin et al. (2021), a retained surgical item is regarded as a "never event" since it is mostly avoidable yet has serious patient, physical, and hospital implications. After a hysterectomy, the straight needle in the Ives v. Australian Capital Territory case stayed inside the patient's body and moved from her abdomen to a chamber in her heart. This put the patient in a potentially fatal danger and indicates that the surgical count was either improperly completed or incorrectly before closure, as there was no reported discrepancy in the number of needles. Hence, failure of surgical safety during the count process is one of the key factors contributing to the sentinel event in this case.

- Inadequate documentation and record-keeping

According to the case given, needle counts were not recorded in the patient's medical file and were merely noted on a whiteboard during the procedure. Because of this, there were no records or comprehensive paperwork to confirm what happened during her hysterectomy procedure. As a result, this made it more difficult to investigate the incident and brought attention to the improper paperwork and record-keeping. According to Søndergaard et al. (2017), nurses document not only to protect their own legal standing but also to prevent mistakes for patients, enhancing patient safety. This is because patient safety and the continuity of nursing care for surgical patients depend on precise documentation and appropriate medical record keeping. This factor was significantly missed, contributing to the sentinel event in this case study.

Reference

Søndergaard, S. F., Lorentzen, V., Sørensen, E. E., & Frederiksen, K. (2017). The documentation practice of perioperative nurses: a literature review. Journal of Clinical Nursing, 26(13–14), 1757–1769. https://doi.org/10.1111/jocn.13445

Weprin, S., Crocerossa, F., Meyer, D., Maddra, K., Valancy, D., Osardu, R., Kang, H. S., Moore, R. H., Carbonara, U., J. Kim, F., & Autorino, R. (2021). Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review. Patient Safety in Surgery, 15(1), 1–10. https://doi.org/10.1186/s13037-021-00297-3

Across the cases, the most common contributing factor to the sentinel events was the failure to detect and remove a surgical item before wound closure. Despite the standard practice such as surgical counts and final wound inspections, items remained inside patients’ bodies.

=> According to Freitas et al. (2016), scrub and scout nurses are in charge of the manual count prior to the procedure, during the closure of the incision, and at the conclusion of the procedure, as well as cross-referencing the number on the sheet with the number of objects in the sterile field to prevent such sentinel incidents. To ensure that the final counts are accurate, this would identify disparities in the surgical counts, escalate the inaccurate numbers to the surgeons, and search for the missing items.

- Breakdown communication among surgical team members

Lack of communication between surgeons and nursing staff was another prevalent issue that contributed to the sentinel events in these situations. There was a failure to record objects that were purposefully kept, which led to missing paperwork, a failure to communicate and transfer information about patients' held items between healthcare facilities; and a failure to raise the discrepancy in final counts during the procedure.

=> Closed-loop communication and a robust safety culture to voice concerns or disparities in surgical counts guarantee that all members of the surgical team are on the same page. Despite having different professions, team members shared the same responsibilities to ensure that surgical items do not go missing during surgical procedures (Prentice, 2021).

- Inadequate documentation and record-keeping

Another common factor was inadequate documentation. It was challenging to look into accidents, determine what happened during surgery, and defend or settle legal claims due to missing count sheets, poor operating records, and inadequate documentation of retained goods or handovers.

=> Surgical count documentation is necessary to prevent such sentinel events. This includes making sure that all consumables and instruments are accurately recorded and documenting any purposefully kept items that could be easily transferred if patients were to be transferred to different medical facilities. Documentation reflects the nursing tasks being finished and the patient care given, according to Søndergaard et al. (2017).

References

Freitas, P. S., Silveira, R. C. de C. P., Clark, A. M., & Galvão, C. M. (2016). Surgical count process for prevention of retained surgical items: an integrative review. Journal of Clinical Nursing, 25(13–14), 1835–1847. https://doi.org/10.1111/jocn.13216

Prentice, R. (2021). Surgical Teamwork and the Pragmatic Ethics of the Outcome. Medical Anthropology, 40(4), 361–374. https://doi.org/10.1080/01459740.2021.1892666

Søndergaard, S. F., Lorentzen, V., Sørensen, E. E., & Frederiksen, K. (2017). The documentation practice of perioperative nurses: a literature review. Journal of Clinical Nursing, 26(13–14), 1757–1769. https://doi.org/10.1111/jocn.13445

- Perioperative nurses must count aloud and collectively for all surgical counts so that the surgical team is aware of what is happening and understands that they should not interrupt.

- Counting should be done with little disturbance since distraction during counting might lead to errors or wrong reporting of the items counted.

- Swabs and sutures must be kept in their original packaging until tallied to avoid inconsistencies.

- All team members are in charge of preventing RSIs.

- All surgical counts should be conducted using the same counting approach.

- When a count disparity is discovered, team members should take steps to identify and locate the missing item.

References

Fencl, J. L. (2016). Guideline Implementation: Prevention of Retained Surgical Items. AORN Journal, 104(1), 37–48. https://doi.org/10.1016/j.aorn.2016.05.005

Warwick, V., Gillespie, B., McMurray, A., & Clark-Burg, K. (2021). Undertaking the surgical count: An observational study. Journal of Perioperative Nursing, 34(3). https://doi.org/10.26550/2209-1092.1089

Whilst the Royal Melbourne Hospital (RMH) count sheets are comprehensive, there are additional small miscellaneous items (SMIs) that should be counted to prevent RSI sentinel events (Australian College of Perioperative Nurses, 2025).

SMIs that should be included in RMH count sheets include:

-              Items that are being placed inside of wounds or cavities that may be left behind, especially if they are cut into smaller pieces, such as rulers and Penrose drains used as retraction. If the ruler or Penrose drain are to be cut into smaller pieces, these additional pieces should also be counted as is done with vessel loops.

-              SMIs comprise multiple elements and are detachable, that may end up in wounds or surgical sites, including pen lids and hypodermic caps. Thus, when counting hypodermics, the lids should be included in the number written down, for example, a single hypodermic should be counted as ‘2’, with the needle and the cap being individual items.

-              SMIs that are placed in surgical fields, especially if they are not embedded with x-ray technology for identification on x-ray. This could include paediatric feeding tubes used as suction for micro-surgical cases, laparoscopic port cleaners that may be lost in the abdominal cavity after use and Haemoclip packets that could end up in a cavity or wound if care is not taken and are left in the surgical field or drapes.

-              As with surgical gauze and packs, dressing gauze if opened prior to the final count or wound closure and huck towels should be included in the count as they are not identifiable with x-ray and could unintentionally remain in a surgical wound if care is not taken.

-              Intentionally retained objects from prior surgical procedures that are being removed should be accounted for to ensure that all objects are removed as intended and the correct length and or/number of implants are removed, for example, screws, plates and k-wires (Fencl, 2016).

Australian College of Perioperative Nurses. (2025). Standards for perioperative nursing.https://www.acorn.org.au/standards

Fencl, J. L. (2016). Guideline Implementation: Prevention of Retained Surgical Items. AORN Journal, 104(1), 37–48.

WHO also provides surgical safety checklists for sign-in, time-out and sign-out, which act as important ‘hard stops’ to promote patient safety before, during and after a procedure. These checklists help identify and mitigate potential errors before they occur and, when consistently followed, reduce the risk of sentinel events (WHO, 2009).

Specifically for sentinel events involving retained surgical items (RSIs), there are also guidelines in place to help prevent these events from occurring. AORN outlines four key aspects aimed at preventing RSIs:

1. Standardised surgical count procedures – counting procedures that are consistent, standardised and adhered to before, during and after surgical procedures.

2. Team communication and accountability – effective communication and shared responsibility within the operating theatre are vital for RSI prevention. Every team member plays a role in ensuring a correct count, with an emphasis on clear and assertive communication to avoid misunderstandings.

3. Use of adjunct technology – the use of radiofrequency identification tags, barcodes and X-ray alongside manual counting helps reduce the impact of human factors that can contribute to RSIs.

4. Education and training – regular education, training and auditing of counting protocols, along with ongoing education regarding available adjunct technologies, helps reinforce safe practice.

(Swartz, 2024)

A consistent approach to the surgical counting process should also be followed throughout all surgeries to help reduce the risk of RSI’s. This includes both the scrub and circulating nurse actively viewing and audibly counting each item together, documenting any pack/raytec intentionally placed within body cavities in a way that everyone can see, maintaining an organised sterile field, and making sure all countable items opened during the surgery are added to the count sheet (AORN, 2016).

REFERENCES

Aorn. (2016). Guideline at a glance: retained surgical items. AORN Journal, 104(5), 474–477. https://doi.org/10.1016/s0001-2092(16)30704-9

Swartz, Z. (2024, August 30). Prevention of Retained Surgical Instruments: AORN's Surgical Count Guidelines. Aorn.org. https://www.aorn.org/article/understanding-retained-surgical-items-(rsi)--importance--prevention--and-aorn-guidelines

World Health Organisation [WHO]. (2009). SAFE SURGERY SAVES LIVES. In World Health Organisation. https://iris.who.int/server/api/core/bitstreams/8f73eee4-051c-4ba3-a47e-5fce82c9f2c8/content

It is within the category of miscellaneous items that I believe the current counting procedures at RMH could be improved. Although the RMH count sheets are comprehensive and provide space for additional items to be manually added, there are still several items that are not routinely counted despite having the potential to be retained within the patient, creating an unnecessary risk to patient safety.

Some examples of items I believe should be routinely included on the count sheet are:

• Plastic rulers (which surgeons commonly use within body cavities and may request to be cut)

• Skin marker caps

• Haemoclip/Weck clip cartridges

• Haemostatic agent applicators, including the interchangeable nozzles or attachments that are inserted into body cavities during both laparoscopic and open procedures

• Huck towels

• Hypodermic needle caps

While there is currently space to manually add these items to the count sheet, and it is common practice for nurses to account for items such as hypodermic needle caps during the count, this is not a standardised process. Instead, it is often left to the individual nurse’s judgement as to which miscellaneous items should be included.

I believe incorporating these items directly into the standard RMH count sheet would improve consistency across all procedures, remove ambiguity from the counting process, and ensure every patient receives the same thorough and systematic approach to preventing retained surgical items. Standardising these counts would strengthen patient safety by providing perioperative nurses with a clear checklist of all items that should be accounted for during every surgical procedure.

REFERENCES

IFPN. (2019). Guideline for surgical counts. https://www.ifpn.world/application/files/1715/7951/7011/1002__Surgical__Count__.pdf