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January 13, 2026

The count was right — until it wasn’t: How surgical miscounts expose fragile safety nets

By: Sree Ponnaluri-Wears, MPH, CIC
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Retained surgical items (RSIs) remain among the most preventable yet persistently recurring surgical “never events.” Despite decades of implementing process checklists, counting protocols, and technology solutions, surgical items continue to be left inside patients across the country.

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