The unintentional retention of surgical items (RSIs) is considered a "never event," yet it continues to occur. In an analysis of a nationwide voluntary event reporting database, unreconciled counts and confirmed unintentionally retained surgical items were reported in over 2,000 events during a two-year period. Many of these events seemed to have occurred as a result of deviation from the AORN recommended practices for the prevention of RSIs. However, the analysis also suggested that organizational culture, fatigue, distractions, communication breakdowns, normalization of deviance, and overconfidence bias may be significantly contributing to the occurrence of RSIs.
During the ASHRM 2017 Conference, Catherine Pusey, associate director, ECRI Institute PSO, and Gail Horvath, senior patient safety analyst at ECRI Institute, will lead a session titled "RSIs: What the Data is Telling Us."
In this session, Pusey and Horvath will discuss the many factors that may be responsible for the occurrence of unintentionally retained surgical items and why the presence of an evidence-based count policy and use of adjunct technology may not be the answer.