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3 Team Actions to Prevent Unintentional RSIs

Protecting a patient from an unintentionally retained surgical object takes a team sharing and applying knowledge about the safest approaches to prevent any retained surgical item (RSI). Unfortunately, this team approach doesn’t happen enough, and patients pay the price.

For years, unintentional RSIs have remained one of the most frequently reported sentinel events. AORN knows this frequency is far higher than reported and we also consider the number of near misses that occur when this dangerous patient safety error is caught just in the nick of time.

Research shows that specific actions can prevent RSI and teams can leverage this evidence in several ways to protect their patients, according to Senior Perioperative Practice Specialist Julie Cahn, DNP, RN-BC, CNOR, ACNS-BC, CNS-CP, lead author of the recently updated Guideline for Prevention of Unintentionally Retained Surgical Items.

“While we can’t always identify every RSI risk before a procedure, we can plan for how we will work together as a team to prevent RSIs if an unexpected procedural event occurs,” Cahn stresses.

Putting Knowledge into Action

Cahn suggests these three actions that any periop team can take to make a fresh commitment to preventing unintentional RSIs from harming patients.

  1. Refresh Team Knowledge on Unintentional RSI Prevention

Extensive updates to the AORN guideline on preventing unintentional RSI include more in-depth discussion on contributing risk factors for RSI such as human factors, communication breakdown, and failure to follow policies and procedures. Updates also include new recommendations to prevent retained foam pieces from negative-pressure wound therapy devices, and new recommendations to prevent intravascular RSIs, such as guidewires.

A major change in this update is a new recommendation to use adjunct technology for accounting soft goods. Research cited in the guideline shows how some types of adjunct technology devices reduced the rate of count discrepancies, decreased time reconciling count discrepancies related to soft goods, and decreased costs associated with count discrepancies, such as costs for radiological imaging.

“Specific adjunct technology devices have significantly higher accuracy rates for identifying retained soft goods compared to manual counting processes. However, manual counting continues to me important and a recommended practice,” Cahn says.

Teams can start learning together about evidence-based updates in the guideline from these resources:

  1. Discuss Data on RSIs and Near Misses as a Team

The latest sentinel event data (PDF) from The Joint Commission can be an important starting point to get your team thinking about RSI, Cahn shares. She says another important source of data on RSI occurrence will come from your own workplace. “Take time to discuss unintentional RSI severe adverse events and near misses that have occurred to understand risk factors and safety gaps most relevant to your workplace setting.”

If you don’t have RSI data, conduct a gap analysis, which you can find tailored for unintentional RSI in AORN’s Gap Analysis Tool for Retained Surgical Items.

  1. Participate in the New AORN Center of Excellence Education Program for RSI Prevention

As part of AORN’s commitment to preventing unintentional RSIs, a new education program has been created that builds off evidence in the updated guideline to give facilities a way to earn public recognition and confirm commitment to the highest levels of patient safety as an AORN Center of Excellence in Surgical Safety: Prevention of RSI after completing the program’s training.

The program covers evidence on human behaviors and environmental influences that lead to unintended RSI, as well as practices for accurately counting surgical items, increasing counting compliance, and reconciling count discrepancies with adjunct technology. Currently, there are several hundred facilities in the process of enrolling in the program and 47 facilities that are fully enrolled and seeking award.