4 Steps to improve RSI prevention

Experts are seeing a shift in practices for preventing retained surgical items (RSIs) as OR leaders update RSI policies to align with AORN’s current Recommended Practices for Prevention of Retained Surgical Items.

“Policy change can be destabilizing and lead to error, but a miscount or retained sponge is a canary in the surgical coal mine signaling the need for conversation and collaboration to refine attitude and action,” says Verna Gibbs, MD, FACS. She is director of the NoThing Left Behind­® surgical patient safety project, professor of clinical Surgery at University of California San Francisco Medical Center, and attending surgeon at the San Francisco Veterans Affairs Medical Center.

“Like wearing your seat belt every time you get in the car, using the right practices and having policies in place for RSI prevention can provide that needed protection to keep the patient from leaving the OR with anything in their body that wasn’t intended to be there,” Gibbs stresses.

She says OR leaders may need to adjust their RSI “seatbelt” by refining policies, practices and even basic language used to describe RSI.

Here are 4 steps to make it happen:

Step 1: Change RSI vocabulary
Nix the term “counts” and replace it with “accounting,” even in casual conversation.

“We account for surgical sponges by placing all of them in a holder at the end of the case to show that they are all in one place. It’s important to have a standardized practice for knowing exactly where every surgical item is before the patient leaves the OR,” Gibbs says. “Just counting is not enough.”

The circulator should also replace terms like "sweep" or "swish" with “methodical wound exam” when asking the surgeon to check that all surgical items are out of the patient.

Step 2: Respect different RSI roles within the surgical teamShare the accounting process and respect the content domains of each team member.

“We don’t expect surgeons to count the sponges, that’s where the circulator is the content expert. The surgeons have to do their part by practicing a complete methodical wound exam in every case,” Gibbs acknowledges. “This isn’t always easy, but it will be easier if a nurse isn’t mandating a surgeon’s action or expecting them to maintain awareness of where sponges are while they are performing the operation.”

Step 3: Clean up policy language
Remove any RSI policy language that is ambiguous or opens the door for judgment, and replace it with concise, directive language.

Gibbs often sees RSI policy statements that require the nurse to judge if a surgical item could be retained. She says this ambiguity sets up the team to fail.

Good RSI policy statement: Sponge counts must be performed in all cases in which surgical sponges are used.

She also suggests outlining a specific accounting practice in the policy, so everyone is accounting for surgical items in one way, the same way.

Step 4: Use miscounts to evaluate areas for improvement
Document miscounts or near misses and bring together a team to identify causes and seek solutions.

“If these events ‘happen all the time,’ that’s the best reason to start examining why that is,” Gibbs says. “Track incidents of miscounts and gather a multidisciplinary team to seek creative solutions to the problems which arise.”

Additional resources
Review a sample multi-stakeholder policy for RSI prevention and other resources for RSI policy development at nothingleftbehind.org.

Find AORN’s Recommended Practices for Prevention of Retained Surgical Items.