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​​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.

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​Catherine Pusey, MBA, RNPusey_Cathy.jpg

Associate Director, ECRI Institute PSO

Catherine Pusey has over 40 years of experience in healthcare, spending the past eight years at ECRI Institute. Prior to joining ECRI, she served as the director of quality and risk for a new start up facility. Her role included designing the quality and risk program, infection control program, compliance program and on boarding of new clinical staff. Her efforts resulted in a deficiency-free State and CMS survey. Her role was expanded to assist other facilities in the system whose licensure or accreditation status was in jeopardy.

Other topics Pusey speaks on include:

  • Patient Safety Evaluation System (PSES) 101
  • Patient Safety Organizations—Definition, Overview, and Benefits


Gail M. Horvath, MSN, RN, CNOR, CRCSTPusey_Cathy.jpg

Senior Patient Safety Analyst IV, ECRI Institute

Gail Horvath has over 30 years of experience in acute care, quality, risk and patient safety. Before coming to ECRI Institute, she was the perioperative educator for a level one trauma center performing over 13,000 surgical cases annually. Gail has also worked as the Clinical Director for Perioperative Services as well as a system manager for perioperative business services in a multi hospital system.

Other topics Horvath speaks on include:

  • Establishing Collaborative Relationships Between the OR and CSP
  • Improving Patient Safety in the OR through PSO Participation

​The ASHRM 2017 Conference will bring together healthcare risk management thought leaders and field experts to share their successes, challenges, and best practices. Patient safety specialists and healthcare risk managers will have the opportunity to increase their knowledge and learn about the latest trends and developments in the field.

Visit the ECRI Institute booth​ for information on how our experts can assist you with your patient safety questions.

Washington State Convention Center
800 Convention Place
Seattle, WA 98101

​Visit the American Society for Healthcare Risk Management website for more information and to register for the ASHRM 2017 Conference and Exhibition.