Four classes of RSIs

Patient Safety Monitor Insider

August 5, 2015

Everyone has heard the horror stories. A patient comes to the hospital with debilitating abdominal pains. Test come back negative, but the pain persists. Finally, either through additional testing or surgery, it’s revealed that a surgical instrument was left in the patient.

The instruments vary. Sometimes it’s a 6-inch surgical clamp or a 13-inch retractor. The most common retained device is a malleable retractor, but other instruments include surgical sponges, guide wires, or small broken pieces of surgical instruments.

The good news is that retained surgical items (RSI), categorized by CMS as a non-reimbursable “never event” are relatively infrequent. Incomplete reporting data makes it difficult to pinpoint the frequency of RSIs, but it’s estimated that as many as 4,000 cases occur each year. Previous studies estimate that these incidents occur anywhere between one in 100 to one in 5,000 cases.

The bad news is that the consequences of RSIs can be devastating for patients, causing dangerous infections or even death.
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