Hide and seek, the search for a missing swab: a critical analysis

This article explores the root causes of a missing swab incident. It reinforces the scrub practitioner's responsibility for the surgical count as reflected on by a student operating department practitioner. With environmental pressures and methods upheld by the operating room culture it is recognised that mistakes do sometimes arise from human error when the stress from workload becomes apparent. Through reflection, mistakes can become learning opportunities, as sought through this critical appraisal.