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Second victims in the operating theatre are often overlooked in patient safety discussions. When retained surgical swabs occur, the impact is not only on the patient but also on the surgical team’s psychological safety.

A new 2025 study has quantified just how deep that ripple of harm runs inside the operating-theatre team, and the numbers should make every peri-operative leader pause.

Understanding Second Victims in the Operating Theatre

Researchers from Hamad Medical Corporation and four international universities surveyed 100 frontline clinicians who had been involved in an adverse-event investigation during the pandemic years. Using the validated Second-Victim Experience and Support Tool (SVEST), they mapped the emotional and professional fallout that followed each incident. Lippincott Journals

Key findings

In other words, one in three clinicians thinks seriously about walking away after a serious error, and nearly half question their basic competence. Lippincott Journals

Retained Surgical Swab Prevention Saves Lives, and Careers

Retained surgical items (RSIs), especially sponges and swab, are among the most preventable “never events.” Yet when they do occur, they often involve multiple staff members:

• Scrub and circulating nurses counting under pressure
• Anaesthetists juggling competing tasks
• Surgeons racing the clock and the patient’s physiology

That shared responsibility is exactly why RSIs are cultural detonators. A single mis-count can:

1. Shatter psychological safety – Staff hesitate to speak up the next time they sense something is off.
2. Trigger attrition – Those 39 % who think about leaving take valuable experience out the door.
3. Drain performance – Self-doubt and fatigue degrade future decision-making, increasing the risk of another incident.

Left unchecked, the human cost compounds the clinical and financial costs we highlight each week in our Hidden Toll series.

Building Psychological Safety for Surgical Teams

The 2025 study doesn’t just diagnose the problem, it points to solutions:

1. Visible, non-punitive support programmes
   More than half of clinicians said institutional support was available, but a worrying 31 % still felt their well-being was low priority. Closing that perception gap is critical.
2. Process fixes that remove error traps
   When counting is manual, cognitive load spikes at the worst possible moment. Simple, tactile aids (our focus at iCount) do more than stop an RSI, they protect morale by making “doing the right thing” the easy thing.
3. Routine second-victim debriefs
   Formal peer-support or Schwartz-round models give staff a safe place to process guilt and anxiety before it hardens into burnout.

Where iCount fits

We built iCount because the safest culture starts with the safest process. Our tactile counting dock:

• Tracks every swab in real time without apps, Wi-Fi or extra screens.
• Slashes cognitive load so scrub teams can focus on the patient, not the arithmetic.
• Signals completion visually, closing can’t begin until every marker is matched, giving everyone in theatre shared confidence.

By eliminating the most common root cause of RSIs, we also eliminate one of the most corrosive blows to team culture.

The takeaway

The new data are a stark reminder: retained swabs create second victims as surely as they create first victims. Preventing the error is the surest way to protect both.

If you’d like to see how a simple human-factors tool can reinforce safety and morale, let’s talk.