A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

April Carmack; Jahnavi Valleru; Kelly H. Randall; Debra Baka; Jesse Angarano; Richard Fogel

Study

A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

November 30, 2022

Carmack A, Valleru J, Randall KH, et al. Jt Comm J Qual Patient Saf. 2023;49(1):3-13.

View more articles from the same authors.

Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.

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A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner

Retained Surgical Items: Definition and Epidemiology.

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Retained Surgical Items: Definition and Epidemiology.

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