Retained surgical items (RSI) are a never event. This article describes implementation of an evidence-based improvement project to reduce RSI and increase reporting of RSI near misses. An important aim was to improve teamwork and assertive communication between operating room (OR) team members, which was achieved through use of the TeamSTEPPS program. Change in staff attitudes about teamwork was measured using the Teamwork Attitudes Questionnaire, which showed improved perceived teamwork.