5 steps to prevent instances of retained surgical items

Although rare, surgical tools or items are unintentionally left inside a patient in about 1,500 out of 28 million surgery operations each year in the U.S., which can result in significant harm. As part of a national workgroup effort, 114 healthcare facilities participated in evidence-based research to identify the best ways to reduce instances of retained surgical items in patient procedures.

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“RSIs are understandably deemed surgical never events, so continued research into their root causes and interventions focused on their prevention and mitigation remain critical,” researchers wrote.

Process changes that place focus on five key priorities were found to significantly improve patient safety and reduce harm by 14 percent. These methods are:

  1. Surgical stop
  2. Surgical debrief
  3. Visual counter
  4. Imaging
  5. Reporting deviations

The five should be done in a “Plan-Do-Check-Act” cycle, authors of the research note, which will increase the likelihood of process improvements and continue to improve patient safety outcomes. 

“Further studies are needed to determine which elements or combinations of elements are more significant for eliminating RSIs, improving surgical safety, and achieving reliable delivery of safe and high quality care to our surgical patients,” researchers wrote in their conclusion.

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