2026 Conference Poster Collection: Patient Safety, Thermoregulation, Retained Surgical Items, and Aromatherapy

PROBLEM IDENTIFICATION: Retained surgical items (RSIs) are a preventable, serious sentinel event that occurs in the perioperative period, often due to communication failure, hierarchical resistance, and lack of inclusivity within the surgical team.Inequitable outcomes may ensue if some team members do not speak up because of unconscious prejudice, cultural factors, or perceived power structures. TEAM DESCRIPTION:This initiative was guided by a multidisciplinary team of perioperative nurses, surgeons, surgical technologists, and anesthesia providers.The team members reflected a range of professional disciplines, levels of experience, genders, and cultures to reflect both the workforce and the diverse patient population being treated. PREPARATION AND PLANNING:The team conducted a gap analysis in accordance with the AORN "Guideline for team communication" and "Guideline for prevention of unintentionally retained surgical items."While counting processes were compliant with policy, the staff response was that not all members of the staff were prepared to report discrepancies or issues, especially junior staff and members of underrepresented groups.Crew Resource Management (CRM), an operational system taken from the field of aviation that is concerned with reducing hierarchy, situational awareness, and inclusive communication, was seen as a way of bridging these gaps.