Beyond the count: Operationalising risk-based prevention of retained surgical items

Inadvertently retained surgical items (RSIs) remain among the most serious and persistent adverse events in perioperative care. Despite their classification as ‘never events’, RSIs continue to occur across surgical specialties and healthcare systems, resulting in avoidable patient harm, professional distress, and substantial medico-legal consequences. Their persistence suggests that the problem is not one of awareness or intent, but of how prevention is conceptualised and enacted in practice.