Preventing surgical instruments from being retained in the patient after surgery has traditionally relied on nurses manually counting instruments used during the procedure. However, this method is not foolproof, and this qualitative study used interviews with operating room personnel to explore reasons for incorrect instrument counts. Not surprisingly, the issues identified are known contributors to safety issues in the operating room, including production pressures, poor communication between physicians and nurses, and overt disruptive behavior. In light of these findings, the authors argue that addressing the persistent problem of retained surgical instruments will require an improvement approach based on safety culture principles.

This article traces the development of a safety culture in a large Illinois health care system and describes its successful use of tactics such as red rules and behavior change to sustain that environment.

This hospital received national recognition for their incentive programs and leadership engagement, and for successfully balancing a culture that supports a "just" approach to error without avoiding accountability. The application of Red Rules, a stop-the-line philosophy, and simplification of administrative barriers helped them achieve an environment that supports safety and learning.