ASHRM 2017: ECRI Institute PSO Speakers Discuss Data on Retained Surgical Items

​In 2016, retained surgical items (RSI) topped Joint Commission's list of reported sentinel events, and in 2017 the problem still made the top three; however, the number of RSI events that are reported to Joint Commission is "really just the tip of the iceberg," according to Catherine Pusey, RN, MBA, associate director, ECRI Institute PSO. Speaking at the American Society for Healthcare Risk Management annual conference on October 17, 2017, in Seattle, Washington, Pusey and copresenter Gail Horvath, MSN, RN, CNOR, CRCST, patient safety analyst and consultant IV, ECRI Institute PSO, presented findings and lessons learned from a recent analysis of 1,987 RSI events reported to ECRI Institute PSO between January 1, 2015, and May 31, 2017. According to the analysis, the most frequently miscounted item, present in 50% of the reports, is the surgical needle, while the most commonly retained item is the surgical sponge, found in 66% of reports with confirmed RSI. In addition, the analysis showed that, in 44% of confirmed RSI cases, retention was not discovered until after the incision was closed; in 31%, retention was discovered after the patient was discharged from the hospital; in 11%, it was discovered after the patient left the operating department procedure area but before being discharged. Another 11% of cases were found before complete closure, and in 3% of cases, not enough information was available to determine when the items were discovered. "That means that nearly 80% of RSI events were found after the incision was closed and after the patient left the surgical area," said Horvath. For cases in which a surgical item was retained, contributing factors included communication issues among staff and team members (24%), policy and procedure issues (17%), staff qualifications and competence (16%), and human factors such as fatigue, stress, taking shortcuts, and distractions (11%).