A Missing Retractor Blade

In practice

At the first layer of closure in an abdominal case, the scrub person, Morgan, and the circulating nurse count instruments against the tray list. The Balfour retractor has come out of the wound and lies on the back table, but one of its blades is not with it. The count is short one item. Morgan says so at once, and the circulating nurse announces it to the surgeon, who pauses the closure. They recount: still missing. The circulating nurse tells the operating room supervisor, as policy requires. The surgeon looks carefully in the wound, along the edges and under the abdominal wall where the blade sat. Morgan checks the Mayo stand, the back table, and under the drapes near the patient's side. The circulator checks the floor and the linen. Then the surgeon finds it: the blade had detached and slipped under the edge of the incision, between the abdominal wall and the drape. It is removed and placed with the rest of the retractor. The count is repeated, and it is now correct. The circulating nurse documents the discrepancy, where the blade was found, and that the count was reconciled before closure. At the debrief, the team notes that the blade's locking screw was loose, and the retractor is sent for repair.