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RSI Contributing Factors: 3 Safety Practices to Consider

Publish Date: March 24, 2021


Despite years of attention and hard work to prevent a patient from leaving the OR with a surgical item left in their body, it’s still the top reported sentinel event for surgery. Over 360 retained surgical items (RSIs) sentinel events were voluntarily reported to The Joint Commission, as of data reported in January 2021.

Perioperative nurse researchers have been working to understand why.

One important finding from this research delves into the events leading up to an RSI event, termed “contributing factors,” as opposed to “risk factors,” and there is a significant difference between the two.

Many of the risk factors leading to RSIs CAN’T be changed, such as if a patient has a high BMI or has significant blood loss during a procedure, explains AORN Senior Perioperative Practice Specialist Julie Cahn, DNP, RN, CNOR, RN-BC, ACNS-BC, CNS-CP. “Even if we knew these factors may increase a patient’s risk for an RSI, there was not much that could be done about it.”

In contrast, contributing factors leading to RSIs CAN be changed because they are underlying realities in the healthcare system tied to human factors, leadership, and communication deficiencies. These contributing factors can include:

  • distractions
  • lack of education
  • inadequate policies and procedures
  • lack of compliance with policies and procedures
  • lack of supervision

“Overall, the risk factors seem to indicate that RSIs are more likely to occur in complex and difficult clinical situations. While this is not surprising, what is important is how we respond when these situations occur. This is where knowledge of contributing factors can help guide practice,” Cahn says. “When it comes to new strategies that can more effectively prevent RSIs, a focus on systems changes that support interdisciplinary collaboration and standardization is crucial.”

Catching RSI Risks Before They Happen

As lead author of the 2022 updated AORN guideline for preventing RSIs—slated for public comment in late July—Cahn is reviewing recent literature that identifies these most prevalent contributing factors.

For example, she says human factors have been reported to be the most common contributing factors in several large studies that separately reviewed different types of unintentionally retained surgical items, such as sponges, guidewires, instruments, needles, blades, and other items.

Cahn is early in the process to draft the 2022 update. However, she discusses these three safety practices targeting RSI contributing factors that demonstrate approaches to protect patients:

  1. Use FDA-cleared adjunct technology to verify soft goods counts.
    Soft goods such as sponges remain the most reported RSIs. Using adjunct technology such as radio frequency identification-tagged sponges and scanning devices can quickly catch a retained sponge before a surgical incision is closed.

    In a recent study of 319 reports of retained soft goods to the Joint Commission, researchers stated that correct use of adjunct technology could have prevented 97.2% of the retained items.

    Cahn says there are a few key points to using this technology: follow the manufacturer’s instructions for use and set pacemakers and implantable cardiac defibrillators to an asynchronous mode when using these devices. “If your facility does not use adjunct technology or allows its use to be waived for certain procedures or scenarios, the specifics should be clarified in the facility count policy and procedure.”
  1. Immediately inspect items used in the surgical wound for breaks or fragmentation.
    When instruments are used incorrectly or are used despite unsafe wear (such as severe staining, cracks, discoloration, and corrosion), research shows that the potential for breakage and fragmentation increases, she explains.

    Minimally invasive surgical instruments present an even greater risk for breakage because these instruments are more delicate and may be more likely to break, she adds. “It may be more difficult to identify minimally invasive device fragments and instrument breakage intraoperatively because of the limited view of the surgical area through the camera and the reduced lighting in the room.”
  1. Minimize distractions, use a standardized checklist, and use two-person verification to confirm guidewires are removed and intact.
    As minimally invasive endovascular procedures are increasing, so are reports of guidewire and guidewire fragment retainment. “Distractions and a lack of standardized processes are part of the problem,” Cahn notes.

    Research suggests that personnel using devices with guidewires need education, training, and competency verification.

    “Because these procedures may be performed emergently by personnel who are unfamiliar with the various devices available, one quality improvement article suggested that using a visual aid posted in rooms where these procedures are performed could help them recognize when the device tip is not intact.”

Share Your Feedback Face to Face

Cahn will be discussing the draft updates to the 2022 guideline for preventing RSIs during an education session on Saturday, Aug. 7 from 11:30 am -12:30 pm at AORN Global Surgical Conference & Expo in Orlando.

She encourages any perioperative professional attending the conference to join her session and share their insights, clinical challenges, and applied solutions to protect patients from enduring the pain and suffering associated with retained surgical items.

In the meantime, you can review these studies on RSI contributing factors:

Related Resources


AORN Journal 
Retained Surgical Items: Evidence Review and Recommendations for Prevention


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