New Strategies to Prevent RSIs

When asked, many perioperative nurses can recall the high anxiety of a “near miss” that sent their team checking under the OR table and searching through trash for a missing surgical item.

Unintentionally Retained Surgical Items (RSIs) – most often surgical sponges, but also things like guidewires and instruments — continue to be the first or second most-reported sentinel event since 2017, despite years of attention and hard work by OR nurses to prevent them.

While rare, the true incidence of RSIs is unknown. It is believed that RSIs are underreported and underestimated. Rates have varied widely depending on the source. The Joint Commission estimates only about 10% of these “never events” are voluntarily reported each year. Studies have estimated approximately 1 RSI per 5,500 cases, and count discrepancies occur in as many as 1 per 8 cases.

Any way you count them, the impacts from RSIs are significant.

For patients, retained items can cause perforation, infection, pain, damage to other body parts, and even death.

For facilities, RSI-related liability settlements average $150,000 per patient. And the cost of one RSI incident in 2014 averaged more than $70,000 in extra, non-reimbursable care. 

Now, recent research on safety practices and new FDA-cleared adjunct technologies are paving the way for practice changes to reduce these risks.

In a Hot Topic session on Saturday, August 7, AORN Senior Perioperative Practice Specialist and guideline author Julie Cahn, DNP, RN, CNOR, RN-BC, ACNS-BC, CNS-CP, presented a preview of upcoming revisions to the 2022 Guideline for Prevention of Unintentionally Retained Surgical Items. The guideline is open for public comment through September 5.

Cahn discussed research about the use of adjunct technologies to augment manual counting procedures, such as radio frequency identification-tagged sponges and scanning devices, to detect a retained sponge before an incision is closed.

She also discussed the most common factors that increase the risk for RSIs like human factors, leadership, and communication deficiencies.

New Prevention of RSI Program Coming

Mitigating risk factors is the basis of a new, multi-faceted perioperative team education and training program launching in early 2022.

With sponsorship from Stryker through the AORN Foundation, the AORN Center of Excellence in Surgical Safety – Prevention of RSI will recognize facilities whose teams complete the multi-disciplinary program that includes:

• Scenario-based immersive technology
• Short, online modules
• Pre- and post-tests on knowledge of unintended RSI
• Gap analysis tools for the OR
• Process audits to confirm progress