Beyond instrument counts: The need for component-wise checklists in operating room safety

Instrument-related safety incidents in the operating room remain an important yet under-recognised threat to patient safety, despite widespread adoption of surgical safety checklists. Retained surgical items and near-miss events continue to be reported in the literature even after the implementation of standardised safety protocols. Modular surgical instruments with detachable components pose unique risks, as component-wise verification is often not routinely practiced. We report a near-miss intraoperative event involving a self-retaining abdominal wall retractor in which a detachable screw was found to be missing at the conclusion of surgery. Although no retained foreign body was ultimately identified, the incident resulted in diagnostic uncertainty and the need for intraoperative imaging. This case highlights a critical gap in current surgical safety practices and underscores the need for component-wise verification of modular instruments to enhance operating room safety and prevent avoidable near-miss events.