To Count or Not to Count: A Surgical Misadventure

An instrument or other surgical item left in the patient is a rare and yet devastating and preventable complication of surgery. Estimates based on claims data suggest the incidence of a retained foreign body to be between 1 in 9000 and 1 in 19,000 operations. The current approach in prevention has been to use the Association of periOperative Registered Nurses' manual counting method. While working at a large academic medical center, a sentinel event occurred where a patient left the operating room with a retained malleable retractor. This article will present the social, cultural, and systems issues that predisposed to that event, the lessons learned, and a summary of evidence concerning these incidents.