AORN Center of Excellence in Surgical Safety: Prevention of RSI


Evidence-Based Education

This evidence-based education raises awareness of factors that lead to RSIs, uses scenario-based immersive technology to improve skills, and helps teams mitigate risks and improve outcomes.

Your facility can earn public recognition and confirm your 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.

Sponsored by Stryker through the AORN Foundation

Stryker Sponsor

  • The behaviors and environmental influences that lead to unintended RSI.
  • Procedures for accurately counting surgical items.
  • Strategies to increase compliance with counting processes
  • Guidelines for reconciling discrepancies, including the use of adjunct technologies to augment manual counts.
  • Pre-Test
  • Eight Education Modules featuring three scenario-based escape rooms!
  • Post-Test
  • Process Audits
  • Recognition Application


  • Aid in reducing or eliminating this sentinel event.
  • Foster a collaborative work environment.
  • Decrease costs associated with retained surgical items.
  • Gain community and national recognition as a Center of Excellence in Surgical Safety.
  • Prevent near misses.


  • $525,000 estimated cost of an RSI.
  • RSIs occur in 1 per 10,000 surgical procedures.
  • Only 67% of RSIs are detected by x-rays.


Ready to take action against RSI?

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The Impact of Retained Surgical Items

  • Estimated cost of an RSI: $525,000
  • RSIs occur in 1 per 10,000 surgical procedures
  • Only 67% of RSIs are detected by x-rays

Need more information or assistance? Contact [email protected]


Cost associated with RSI

Williams TL, Tung DK, Steelman VM, Chang PK, Szekendi MK. Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology. J Am Coll Surg. 2014;219(3):354-364.

Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent recurrence. JAMA Netw Open. 2021;4(5):e217058.

Blanchfield BB, Acharya B, Mort E. The hidden costs of regulation: the administrative cost of reporting serious reportable events. Jt Comm J Qual Patient Saf. 2018;44(4):212-218.


Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80-87

1 per 10,000 Procedures

Guideline for prevention of unintentionally retained surgical items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2022:827-894.

This evidence-based program is made possible from a sponsorship by Stryker through the AORN Foundation.

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