AORN Outlines Evidence-Based Practices to Reduce Retained Surgical Item Risk During High-Complexity Counting Scenarios
DENVER, CO, UNITED STATES, October 21, 2026 /EINPresswire.com/ -- AORN, the Association of periOperative Registered Nurses, is highlighting evidence-based counting practices designed to reduce the risk of unintentionally retained surgical items (RSIs) during four common high-risk moments in surgical and delivery settings. The guidance comes ahead of the November e-release of AORN’s updated Guideline for Prevention of Unintentionally Retained Surgical Items, authored by Renae Wright, DNP, RN, EBP-C, CNOR, Senior Perioperative Practice Specialist at AORN.
“Perioperative nurses can be better prepared when they have a chance to think through examples of how to translate evidence-based recommendations into real-world action,” Dr. Wright said.
Discrepancies in surgical item counts are a key precursor to RSI events, and research shows certain scenarios substantially increase that risk. AORN’s guidance walks through four of these scenarios and the corresponding evidence-based response for each.
Relief Breaks Introduce Counting Disruptions
Changes in personnel during short relief breaks are linked to a measurable rise in count discrepancies. Observational research found a three-fold higher risk of count discrepancy when the RN circulator or scrub person changed during counting activities, compared to when no personnel changes occurred. AORN recommends that the same two individuals perform counts whenever possible, that relief be avoided during critical procedural phases, and that a structured handoff be used to communicate count status when relief is necessary.
Concurrent Wound Closures Divide Attention
Competing priorities during concurrent closures reduce counting accuracy. Closing counts frequently occur while surgical items are still in use, and most closing counts do not follow recommended practice, according to observational research. AORN recommends minimizing distractions and confirming that all surgical items are removed from the patient and returned to the scrub person before completing the count.
Multiple Instrument Tables Add Complexity
Procedures involving multiple instrument tables or sterile fields raise the risk of losing an accurate count as items move between fields. These setups are more common in longer, complex procedures or cases involving multiple teams — circumstances research links to higher RSI risk. AORN advises a simplified, standardized approach of maintaining a single running count and performing one unified final count.
Vaginal Deliveries Carry Distinct RSI Risk
Vaginal deliveries present a unique counting challenge because they begin with one patient and end with two. Observational data found that nearly one-quarter of 319 retained surgical soft good events occurred in the vagina, most often following vaginal delivery, and were frequently not identified until days or weeks later. AORN recommends audibly communicating and visibly recording when radiopaque surgical soft goods are placed in or removed from the vagina, and including the vagina in a methodical exploration before the procedure concludes.
These four scenarios illustrate a broader principle behind AORN’s approach to RSI prevention: translating evidence into concrete, repeatable action at the moments of highest risk. That approach is central to AORN’s updated Guideline for Prevention of Unintentionally Retained Surgical Items, scheduled for e-release in November, which will provide perioperative teams with expanded evidence-based recommendations for RSI prevention across a range of clinical scenarios.
About AORN
The Association of periOperative Registered Nurses (AORN) represents the interests of more than 200,000 perioperative nurses by providing evidence-based resources, continuing education, and advocacy to advance surgical care. AORN is committed to empowering nurses to transform patient experiences before, during, and after surgery.
“Perioperative nurses can be better prepared when they have a chance to think through examples of how to translate evidence-based recommendations into real-world action,” Dr. Wright said.
Discrepancies in surgical item counts are a key precursor to RSI events, and research shows certain scenarios substantially increase that risk. AORN’s guidance walks through four of these scenarios and the corresponding evidence-based response for each.
Relief Breaks Introduce Counting Disruptions
Changes in personnel during short relief breaks are linked to a measurable rise in count discrepancies. Observational research found a three-fold higher risk of count discrepancy when the RN circulator or scrub person changed during counting activities, compared to when no personnel changes occurred. AORN recommends that the same two individuals perform counts whenever possible, that relief be avoided during critical procedural phases, and that a structured handoff be used to communicate count status when relief is necessary.
Concurrent Wound Closures Divide Attention
Competing priorities during concurrent closures reduce counting accuracy. Closing counts frequently occur while surgical items are still in use, and most closing counts do not follow recommended practice, according to observational research. AORN recommends minimizing distractions and confirming that all surgical items are removed from the patient and returned to the scrub person before completing the count.
Multiple Instrument Tables Add Complexity
Procedures involving multiple instrument tables or sterile fields raise the risk of losing an accurate count as items move between fields. These setups are more common in longer, complex procedures or cases involving multiple teams — circumstances research links to higher RSI risk. AORN advises a simplified, standardized approach of maintaining a single running count and performing one unified final count.
Vaginal Deliveries Carry Distinct RSI Risk
Vaginal deliveries present a unique counting challenge because they begin with one patient and end with two. Observational data found that nearly one-quarter of 319 retained surgical soft good events occurred in the vagina, most often following vaginal delivery, and were frequently not identified until days or weeks later. AORN recommends audibly communicating and visibly recording when radiopaque surgical soft goods are placed in or removed from the vagina, and including the vagina in a methodical exploration before the procedure concludes.
These four scenarios illustrate a broader principle behind AORN’s approach to RSI prevention: translating evidence into concrete, repeatable action at the moments of highest risk. That approach is central to AORN’s updated Guideline for Prevention of Unintentionally Retained Surgical Items, scheduled for e-release in November, which will provide perioperative teams with expanded evidence-based recommendations for RSI prevention across a range of clinical scenarios.
About AORN
The Association of periOperative Registered Nurses (AORN) represents the interests of more than 200,000 perioperative nurses by providing evidence-based resources, continuing education, and advocacy to advance surgical care. AORN is committed to empowering nurses to transform patient experiences before, during, and after surgery.
Christian Czerwinski
AORN
cczerwinski@aorn.org
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