Safety Advocacy


Taking a stand together

Government, clinical societies, quality organizations and patient safety groups have taken note of the concerning prevalence of retained surgical items (RSI) and agree there’s more to be done. They’re addressing RSI in various ways including educational efforts, incident reporting, payment structures and protocol recommendations that include adjunctive technology such as the SurgiCount System.

What experts are saying

“A multidisciplinary team may evaluate adjunct technologies for use as a supplement to manual counting.”18
AORN 2016 Guidelines
Recommendation VII

“A systems approach should be used for prevention of RSIs. Healthcare organizations should value learning and respond to errors with a focus on process improvement rather than individual blame.”18
AORN 2016 Guidelines
Recommendation X

“This event [unintended retention of foreign objects] is reflective of system problems and rarely the result of a single individual’s error. Faulty, incomplete, or ineffective systems cause humans to err.”9
ECRI Research Response on Adjunctive Technologies

“The 10 patient safety concerns on this list are very real. They are causing harm—often serious harm—to real people. Fortunately, for all of the patient safety concerns on this year’s list, more can be done.”9
William M. Marella, MBA, MMI
Executive Director, PSO Operations and Analytics
ECRI Institute’s Patient Safety, Risk and Quality Group

“Despite the powerful stories of improving and high-performing hospitals, improvement across the board remains elusive…Hospitals are performing worse on critical measures like foreign objects left in after surgery.”24
The Leapfrog Group
Fall 2015 Hospital Safety Score Report

RSIs are considered an outcomes measure – a measure of harm experienced by patients – and are weighted at 4.2%.25
The Leapfrog Group
Spring 2016 Scoring Methodology

“Safe technology: Research the potential of using assistive technologies to supplement manual counting procedures and methodical wound exploration.”7
The Joint Commission
Sentinel Event Alert

“Authority reports suggest that RSI prevention remains a challenge and that continued diligence in RSI prevention efforts is essential.”21
Pennsylvania Patient Safety Authority
Safety Advisory

“Because counting alone may be insufficient, the Authority presented multipronged risk reduction strategies, including improved perioperative processes, perioperative team communication, and the use of assistive technology.”21

“Manual counting methods are not fool-proof, as they are subject to human error. Newer techniques, which include automated counting and tracking of sponges, appear to increase the accuracy of counting and the detection of inadvertently retained sponges.”27
World Health Organization
Guidelines for Safe Surgery

“Surgeons and nurses are the primary defenders against retention, and only behavior change to actually use these safe practices will prevent patient harm.”23

Verna C. Gibbs, M.D., Director, No Thing Left Behind

Unintentionally retained foreign objects, despite a correct count rank #8 on ECRI’s Top 10 Patient Safety Concerns for 2016.9

Site References

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