Improving Patient Safety and Governing Surgical Count the process through Effective Communication and Teamwork

Author(s): Merlyn C. Tayo

Introduction: A retained surgical item (RSI) is any item inadvertently left behind in a patient’s body in the course of surgery. In the patient’s safety field, this is widely considered a “Never Event” as it is preventable. The consequences of RSI include injury, repeated surgery, excess monetary cost, loss of hospital credibility and in some cases death. Hence, prevention remains a top priority for the perioperative team members and healthcare organizations. Several incidences (Sentinel Events) occurred within the operating rooms related to RSI with recommendations for the Operating Room Services Administration (ORSA) to improve the situation. A short summary of the literature review citing the author and year e.g. Derwing et al. (2002) mentions…etc. Prudent medical practice and laws in all states of the USA, require that medical and surgical items not intended to remain inside of patients, not be negligently left behind. Inadvertently leaving devices, needle, sponges, instruments or other miscellaneous items inside of patients (retained surgical items) is a preventable event is generally considered to be a “never event”. An RSI is a surgical patient safety problem. An event occurs because of problems with faulty procedural practices and poor communication strategies between personnel. To prevent RSIs, it is important to change practice and the exchange of knowledge and information, with an understanding of human fallibility in perception and risk assessment. (Gibbs, Verna C. NoThing Left Behind: The Prevention of Retained Surgical Items Multi-Stakeholder Policy – Job Aid – Reference Manual, 2018)