Retained fragmented Raytec gauze eluding an alleged correct postoperative count following cardiothoracic surgery: case report of a rare “never event”

This case illustrates that retained gauze fragments can occur despite correct counts due to fragmentation of radiopaque markers. Surgeons and operating room nurses should inspect gauzes for integrity, maintain vigilance when manipulating sponges in confined operative fields, and consider adjunct technologies such as radiofrequency or barcode tracking. In high-risk surgeries, postoperative imaging may be warranted even with accurate counts to ensure patient safety.