Twenty-one interviews could be completed (participation rate 75%). Interviews lasted on average 37 min (range: 26–66 min). Of the participating experts, 10 were clinicians and had a leading role in professional perioperative and surgical associations (CLIN-OR). Among these, seven were surgeons or physicians who perform invasive procedures and three were experts in OR management and OR nursing. Three persons were responsible for quality/safety of the cantonal (2) or national (1) health administration (HEALTH-ADMIN). Two experts each were from national health care quality organizations (Q-ORG), national or regional hospital associations (HOSP-ASSO), and patient advocacy organizations (PAT-ADVO) offering support and counseling services to patients. Finally, two experienced clinical risk managers from large hospitals participated (RISK-MGMT). Of all participants, 11 were currently working as health care providers and two had a clinical training but were no longer working in patient care.

Experts’ experience and previous engagement with RFOs

Nine of the clinically active experts (82%) had experienced RFO either personally, as supervisor or within their unit / department. Beyond their efforts in daily clinical routines, RFOs have not been an explicit and major issue of discussion or activity at most organizations participants represented. Two HEALTH-ADMIN and one Q-ORG representative reported that RFOs were among the patient safety indicators that may be introduced in the future for routine safety monitoring and had been discussed in this context. RFOs are among the perioperative events recorded in the quality registry of one CLIN-OR. A CLIN-OR was leading the development of guidelines and standards for surgical counting procedures. One expert referred to instances in which his HOSP-ASSO provided advice to management and legal handling of RFO events to member hospitals. Many CLIN-OR experts spontaneously mentioned that efforts to prevent RFO have changed dramatically in the last decades with some surgeons showing some concern about the increasing sophistication of counting procedures, their complexity and required time in the OR.

RFOs as a safety problem: factors contributing to RFOs

Experts mentioned a variety of factors contributing to the occurrence of an RFO. Lack of standardized counting policies and procedures, specifically with intraoperative handovers in the team, human error in counting and false-negative surgical counts were seen as an important risk factors for RFO by CLIN-OR and Q-ORG representatives.

If you have two hundred plus cloths, and the OR team changes three times, and there is no count at shift changes – you make the door wide open.

Quote CLIN-OR nursing representative (id 9)

Time pressure, fast-paced work processes and high levels of experienced stress in the OR were one of the most commonly mentioned causes, in particular by CLIN-OR. They were brought forward in the interviews as reasons for loosing items intraoperatively, and for making errors during counting procedures, which itself adds to stress and pressure when it requires time to resolve discrepancies. “Productivity pressure” was clearly very present in the lived experiences of those working in the OR.

The risk is higher in routine surgeries. It is not the emergencies, it is the routine elective procedures, when you quickly want to get finished. When it goes “fast, fast, fast”, “hurry”. Poorly planned OR times and then there is hurry and stress.

Quote CLIN-OR OR management representative (id 3)

Culture in the OR, teamworking and communication among staff was another dominant theme that emerged. Experts referred to hierarchy between the different professions and a lack for clarity of roles and responsibilities which could contribute to RFO incidents. Some CLIN-OR experts mentioned past generations of surgeons who would sometimes contribute to tensions between team members in the OR through rude or authoritarian behaviors. Time pressure and culture were sometimes explicitly connected by clinicians bringing up the same example: The surgical count reveals a missing item and a surgeon is hurrying to leave the OR to get to the next surgery. Experts argued that speaking up can be very difficult for OR personnel under such circumstances but would be required to prevent RFOs. Unexperienced or temporal staff and intraoperative changes in the team were seen as factors that further complicated speaking up.

Information on items may not be handed-over correctly when multiple surgical teams are involved. When a surgeon then tells me "you cannot count" it is difficult to speak up.

Quote CLIN-OR nursing representative (id 6)

Eighteen experts (including all surgeons) referred to the surgeon as being primarily responsible in case an RFO happens. Three persons each named surgeon and scrub nurse, surgeon and team, or surgeon and hospital.

As a surgeon, you have to rely on the scrub nurse. If she confirms that everything is clear and the count is correct – what should I do? But I have to go to the patient afterwards to inform him when she lost an item.

Quote CLIN-OR surgeon representative (id 17)

Three experts (PAT-ADVO; Q-ORG; CLIN-OR nursing) said the entire OR team would be responsible for an RFO without mentioning surgeons explicitly.

RFOs as a safety problem: preventability of RFOs

All experts agreed that RFOs are largely preventable, but their framing differed. CLIN-OR representatives argued that RFOs could be reduced only to a theoretical minimum while other experts in contrast emphasized their virtually complete preventability.

Human errors occur – you cannot eliminate it.

Quote CLIN-OR surgeon representative (id 8)

Very, very close to 100% preventable.

Quote HEALTH-ADMIN representative (id 1)

When you comply with all procedures – it cannot happen.

Quote RISK-MGMT representative (id 14)

One surgeon representative specialized in high-risk procedures elaborated on deliberate intraoperative decisions to minimize patient harm, which could mean to accept loss of an item temporarily.

To prevent every single case is difficult. It can be a trade-off. In principle, it is preventable, but you have to consider the consequences. When you have a seriously sick patient in the OR who should go to the ICU immediately, you have to raise the question whether it makes sense for the patient to count cloths for half an hour. But in routine surgeries, there should be no trade-off.

Quote CLIN-OR surgeon representative (id 4)

A patient advocate made an interesting reference to RFO malpractice cases in which his organization supported patients.

Patients are not compensated straightforward if it happens. So the legal system obviously does not think that it is completely preventable. But in theory, yes, it is preventable. RFOs could be the type of events that should be directly compensable.

Quote PAT-ADVO representative (id 7)

RFOs as a safety problem: Relevance of RFO as a safety issue on the national level.

On the systems level and compared to other safety issues, RFO were seen as having less urgency in Switzerland by most experts. The main consideration expressed was that a very small number of patients is affected by RFOs and while for the individual patient the event could be catastrophic and the level of suffering could be substantial, medication safety or surgical site infections put much larger numbers of patients at risk.

For the specific patient it is a serious problem, but it is not a systematic problem. We are probably at the margin to the maximum achievable safety.

Quote CLIN-OR physician representative (id 16)

Several CLIN-OR representatives related RFOs and the associated harm to other patient safety issues of more relevance on the systems level, and explicitly named Swiss data protection law and poor health information technology in hospitals. They were arguing that barriers to the fast and easy exchange of relevant clinical information would make it difficult for them to provide safe care, in particular in emergencies and high-risk surgeries.

There a much more people dying from poor digitization in Switzerland than from RFOs.

Quote CLIN-OR surgeon representative (id 4)

PAT-ADVO and RISK-MGMT representatives explicitly compared RFOs to diagnostic errors which would be much more frequent but more complex and harder to detect and to approach. One expert of a national quality organization referred to the wider relevance of RFO on the national level.

Based on the number of events and level of harm it is not so much an important safety issue. But it reflects our culture on how we look at things, and that is why it is important. Because it is so much perceived as an event of individual failure, it is hard to discuss and look at.

Quote Q-ORG representative (id 2)

All experts, except one PAT-ADVO and a HEALTH-ADMIN representative who both referred to lack of data, unequivocally agreed that they expect relevant differences in the RFO rates between hospitals across the country. Two main arguments were brought forward to substantiate this view: Differences in hospitals’ safety cultures and priorities of local leadership, as well as differing strengths of economic orientation in hospitals.

What is the main interest of hospitals, economic orientation and production pressure? How far can you squeeze the lemon? Less scrub nurses, less time in the OR. If you have poor work conditions in the OR, more foreign personnel.

Quote CLIN-OR physician representative (id 16)

There are cultural differences between hospitals. Hospitals with chief medical officers who have understood the surgical safety checklist make the difference. I expect that more happens at places were the checklist has not been understood.

Quote RISK-MGMT representative (id 14)

Absolutely yes; without knowing the numbers; differences in implementation of prevention efforts – resulting from culture.

Quote HEALTH-ADMIN representative (id 1)

I expect higher risk in very economically driven institutions; attending surgeons and hospitals may have conflicts of interests. For in-depth analysis of these events I would concentrate on hospitals with a attending surgeon system.

Quote HOSP-ASSO representative (id 5)

In addition, some CLIN-OR experts mentioned differences in case-mix, general surgical volume, volume of high-risk surgeries, surgical disciplines, surgical team’s experience, and other more clinical aspects that would impact the RFO risk at these specific hospitals.

RFO incidence in international comparison

All CLIN-OR and HOSP-ASSO representatives believed that Switzerland has lower, or essentially equal RFO incidence rates compared to other high-income countries. Three experts (one HEALTH-ADMIN, one PAT-ADVO and one RISK-MGMT) expected Switzerland to have higher rates. Of the 21 experts, only three were aware that there is international comparative data on RFO incidences available (one HEALTH-ADMIN, one PAT-ADVO and one CLIN-OR). No surgeon was aware of the availability of national data.

When confronted with the slide showing the OECD international ranking by RFO incidence (Fig. 2), most experts were surprised by the Swiss position. Initial spontaneous reactions were dominated by comments on the country’s position relative to others and concerns related to data sources and data quality. This skepticism was prominent across all groups of experts.

I simply do not believe these figures.

Quote CLIN-OR surgeon representative (id 4)

There is no statistical measure of variability or data quality included. So you cannot know whether it is really significant.

Quote HEALTH-ADMIN representative (id 10)

What you can see is that Switzerland is very good in reporting [laughter].

Quote CLIN-OR surgeon representative (id 8)

Impressive! If that is really the case, we are leaders in the negative sense. Is there a coding effect? What are the others making better? This figure raises several questions.

Q-ORG representative (id 11)

Differences in reporting? Are there economic incentives which differ between countries?

Quote PAT-ADVO representative (id 7)

This is concerning. Are these cases all clinically relevant to the patient? If these are all patients suffering, that rate is too high.

CLIN-OR physician representative (id 16)

The coding quality is very high in Switzerland, in particular if something is reimbursable; If it is not reimbursable in other countries, that could explain the differences.

Quote HEALTH-ADMIN representative (id 21)

When asked whether the international comparative data by and large reflect reality, two confirmed, fifteen experts clearly declined, and the remaining did not provide an answer. Elaborating on their concerns regarding the validity of the OECD comparison, the main reason expressed was the relation between countries. They believed that Switzerland has high coding standards in hospitals and expected less accurate coding in other countries (i.e., high rates of underreporting). Thus, Switzerland’s position would be an artefact. Some interviewees also mentioned likely underreporting in all countries, including Switzerland, but to varying degrees.

It is completely biased but we cannot know in which direction.

Quote CLIN-OR surgeon representative (id 13)

Only two experts (one CLIN-OR surgeon representative and one RISK-MGMT) acknowledged that coding differences were likely to exist but that these would not serve as a sufficient explanation for reported differences between countries.

We are dramatically worse than 10 other countries. You cannot discuss this away with data quality alone.

Quote RISK-MGMT representative (id 14)

Experts elaborated to explain differences between countries reported by OECD, based on their personal experience and perception of surgical quality and health care system performance of the comparator countries. This “sensemaking” of the data often focused on Scandinavian countries, the Netherlands, Canada, and Italy (a neighboring country).

I cannot believe the Italian figures. How is the coding quality? From Netherlands we could learn a lot. The OR staff from the Netherlands is highly educated and oriented towards quality. I can imagine that they have so small numbers, that seems realistic.

Quote CLIN-OR nursing representative (id 9)

Switzerland and Netherlands and Canada have probably less underreporting.

Quote CLIN-OR surgeon representative (id 13)

Sweden is quite comparable with Switzerland in surgical quality issues. Maybe Canada, Switzerland and Sweden are honest reporters and the others have strong underreporting?

Quote CLIN-OR surgeon representative (id 17)

Data from Sweden, the Netherlands and Israel is trustable.

Quote RISK-MGMT representative (id 18)

Italy surprises me; the authority of the surgeon in Switzerland is probably higher compared to Sweden, where the culture is more participatory. Could maybe explain the difference?

Quote PAT-ADVO representative (id 20)

Experts were trying to balance their views on other countries’ levels of surgical safety with their assumptions towards these countries’ coding practices to explain differences in RFO rates. For some countries, low RFO rates were unequivocally explained by poorer reporting, sometimes complemented by reflections on the lower frequency of high-risk surgery performed in these countries. On the other side, the positions of Netherlands, Finland, and Israel, which have considerably lower RFO rate compared to Switzerland on the OECD graph, seemed to be more troubling for CLIN-OR experts. The perceived level of surgical care and coding quality co-existed for these countries. Thus, from these experts perspectives, there was no obvious reason to question the considerably lower RFO rates of these countries. While verbalizing their thoughts, some experts became self-aware that they were trying to selectively explain figures that confirmed their pre-existing views.

Responding to international RFO data

Independent of the discipline they represented, most experts thought that the publication of the OECD figures should initiate some response on the national level. Deeper investigations and analysis of the data were typically mentioned as a potential first step.

We have to act upon this. I thought that we are at an incidence so low that it cannot be reduced further. But these figures show we are not there at all.

Quote RISK-MGMT representative (id 14)

It is good that we have figures. It requires more in-depth analysis whether we really have a problem.

Quote HOSP-ASSO representative (id 12)

This is not satisfying. We cannot simply leave that statistic without response.

Quote Q-ORG representative (id 11)

Some participants focused the international comparison that would require further analysis to clarify the seize of the problem in Switzerland. Others were orienting on the Swiss numbers “as they stand” and recommended in-depth national analysis and validation studies.

If we would understand the differences between and within countries—we would know what to do and could solve the problem.

Quote CLIN-OR surgeon representative (id 4)

We should investigate the validity of the data: identify clusters, types of surgeries, differences between hospitals and regions, public and private hospitals. And whether there is underreporting; there needs to be a response.

Quote CLIN-OR surgeon representative (id 17)

Two CLIN-OR experts stated they were unimpressed by the OECD numbers and would not recommend further activities or inquiries because there were other issues of higher priority.

Everyone makes efforts to reduce it and you will never reduce it to zero. I would not invest too much time and resources on the topic.

Quote CLIN-OR surgeon representative (id 8)

There was little clarity and no agreement between experts what they expected from different stakeholders in the system and who should or could initiate further activities. In particular, there were different views on regulative interventions. While some experts expected regulative bodies on the cantonal level to initiate discussion with hospitals and surgeons,, others were clearly opposed to this approach.

It is the cantonal regulating bodies’ role to ensure that patients have no elevated risk for RFO regardless of which hospital they go to. The regulative body should take action immediately.

Quote HEALTH-ADMIN representative (id 1)

National standards for counting procedures would help to decrease variation; it is a professional issue, not so much a regulative issue.

Quote CLIN-OR nursing representative (id 9)

Not efficient if the regulator would engage in that. By law the cantons are responsible, but the cantons are not equipped to do that.

Quote RISK-MGMT representative (id 14)

Similarly, there was no consensus on the role of professional associations (e.g., surgical associations). Experts questioned the potential power of surgical associations and also argued that there are too many, usually small, organizations involved in Switzerland.

It does not help much if the professional organizations engage in quality recommendations and guidelines, if nobody controls it. It will only work with economic incentives or control mechanisms.

Quote CLIN-OR surgeon representative (id 17)

Professional organizations can only make recommendations. And that is probably not enough?

Quote CLIN-OR physician representative (id 19)

Hospitals were seen as responsible for efforts to prevent RFO, but whenever they were mentioned, it was acknowledged that external pressure or incentives would be required to trigger specific engagement or improvement activities.

Hospitals should engage, but the economic incentive runs against more prevention. Maybe explicitly pay for the surgical count, so that you get paid for the time? But recommendations and voluntary actions are not enough.

Quote PAT-ADVO representative (id 20)

It requires hospitals and their leadership. But they have so many issues to deal with. A just culture needs to be pushed in hospitals. This would be most sustainable; It will trickle down to the OR teams. But that needs external pressure by cantons and health insurers.

Quote HEALTH-ADMIN representative (id 21)

Two experts mentioned the federal quality commission (introduced in 2022) and suggested that they could be in the position to advance the topic (both HEALTH-ADMIN). Another CLIN-OR surgeon representative argued that he would like to see researchers and analysts in the field to further explore the data. Overall, experts seemed to have no clear vision and expectation of whose responsibility and role it would be to act based on the international data, if at all, and there was obviously no distinct strategy that appeared potentially successful to them.