Penn Patient Safety Authority reviews RSI events, guidelines

Editor's Note

In this advisory, the Pennsylvania Patient Safety Authority reviews retained surgical item (RSI) events in Pennsylvania hospitals and RSI guidelines from various organizations.

Analysis of events reported to the Pennsylvania Patient Safety Authority from 2014 to 2015 reveals 112 RSIs that met the definitions of the National Quality Forum and the Joint Commission and 16 that met the Joint Commission definition alone, for a total of 128 RSIs.

Surgical sponges were the most commonly retained items, followed by small miscellaneous items. Most RSIs were left in the abdomen and pelvis, followed by the vagina and chest.

The advisory was produced by the ECRI Institute and Institute for Safe Medication Practices for the Pennsylvania Patient Safety Authority.

Surgical items such as sponges, sharps, and instruments may be retained during surgery and can lead to serious patient harm. Ongoing analysis of reports to the Pennsylvania Patient Safety Authority suggests retained surgical items (RSIs) remain a challenge to Pennsylvania hospitals.