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Retained surgical items remain one of the most serious and preventable risks in modern healthcare.

A COUNT WAS COMPLETED.

THE PROCEDURE WAS FINISHED.

THE SYSTEM SAID EVERYTHING WAS FINE.

Weeks later, a retained surgical item is discovered.

This isn’t rare.
And it isn’t just human error.

It’s a system problem.

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RETAINED SURGICAL ITEMS ARE NOT RARE

A major investigation by Hearst Newspapers found that:

• At least one patient a day in the U.S. leaves surgery with something left inside them
• Thousands of cases have been reported between 2015 and 2023
• Over 650 cases were reported in a single year (2022) across available state data
• Four patients died in New York alone since 2019 due to retained items

These are described as “never events.”

But clearly… they’re not never.

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WHY RETAINED SURGICAL ITEMS STILL OCCUR

The common belief is simple:

If the surgical count is correct, the patient is safe.

But evidence says otherwise.

Studies show that in over 88% of retained swab/sponge cases, counts were recorded as correct

Let that sink in.

The process didn’t fail because people didn’t count.
It failed because the system allowed a false sense of certainty.

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WHY SURGICAL COUNTS FAIL IN REAL CONDITIONS

Operating theatres are not controlled environments.

They are high-pressure systems where clinicians manage:

• Time pressure
• Changing surgical plans
• Multiple team members communicating simultaneously
• Patient-specific complexities

And in that environment, the system still relies heavily on:

• Manual counting
• Verbal confirmation
• Human memory

That’s fragile by design.

Research shows that  distractions, complexity, and workflow interruptions significantly increase the risk of retained surgical items.

So this isn’t about individuals making mistakes.

It’s about systems expecting perfection under pressure.

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WHEN THE SYSTEM FAILS, THE CONSEQUENCES ARE REAL

When a retained surgical item is missed:

• Patients often require additional surgery
• Infection risk increases
• Recovery is delayed
• Litigation costs can reach hundreds of thousands or more
• Psychological impact affects both patients and clinical teams

And in some cases… patients die.

Retained surgical items are widely recognised as “never events” and are classified as sentinel events by The Joint Commission, meaning they are serious, preventable patient safety incidents requiring investigation and system-level response.

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DESIGNING SAFETY FOR REALITY, NOT THEORY

If the environment is complex, the solution must match that complexity.

Improving outcomes isn’t about telling clinicians to “be more careful.”

It’s about asking:

Does the system actually support them when things go wrong?

Effective safety systems should:

• Reduce reliance on memory
• Provide clear visual confirmation
• Fit seamlessly into existing workflows
• Support teams without adding friction

This aligns with principles from the World Health Organization Surgical Safety Checklist, which emphasises system-based safety over individual vigilance.

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HOW iCOUNT SUPPORTS SAFER SURGICAL COUNTING

iCount was built around one simple idea:

Safety systems should work in real conditions, not ideal ones.

It is designed to:

• Support consistent surgical counting
• Reduce reliance on verbal-only processes
• Improve visibility and accountability
• Strengthen team confidence
• Integrate into existing workflows

It doesn’t replace clinicians.

It supports them when the environment is working against them.

Learn more about iCount and surgical counting systems

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THE REAL QUESTION

Retained surgical items are still labelled “never events.”

But the evidence says otherwise.

So the real question is:

👉 Is your current process truly designed to prevent them?

Or does it simply assume they won’t happen?

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📚 REFERENCES

• Hearst Investigation – Surgical items left inside patients
• Hearst Data Analysis – Retained surgical items across US hospitals
• Hearst Summary – Thousands of retained surgical item cases
• Retained Surgical Items Study (PMC)
• Risk Factors for Retained Surgical Instruments
• The Joint Commission – Sentinel Event Data on retained surgical items
• World Health Organization – Surgical Safety Checklist