Introduction. Intraoperative inconsistencies in the surgical count, such as incorrect counts and discrepancies are known to be a risk factor contributing to retained surgical items. They may lead to serious sentinel events. The analysis of near misses reveals its causes and helps develop proper preventive methods. The occurrence of near misses in perioperative practice should effect in recurring operating room staff training. Aim. The aim of this article is to present a case study of the near miss in the surgical count, propose the principles to follow in case of an incorrect count or discrepancies and prevent the occurrence of similar situations. This case study was described to raise awareness among the surgical team regarding patients’ safety. Case study. The initial surgical counts’ result before emergent explorative laparotomy was in accordance to the amount declared on packages by the producer. The final count conducted before the peritoneal cavity closure was incorrect – one of the radiopaque 10 cm x 10 cm sponge was missing. Conclusions. It is perioperative nurses’ responsibility to maintain the correct surgical count, although every team member of the surgical team plays a role in prevention of unintentional retention of a foreign body in the surgical site. Detailed and insightful procedures which regulate the proceedings with surgical equipment and instruments should be designed to reassure patients’ safety and provide a clear pattern of conduct for the surgical team members.

Key words: near miss, case study, operating room nursing.