RSI Prevention Kick-Off

In 2019, how many unintentionally retained surgical items were reported to The Joint Commission?

• 88

• 144

• 203

• 347

Answer explanation

The number of unintentionally retained surgical items (URSIs) reported to The Joint Commission (TJC) continued to decline in 2022, with 88 events disclosed to the accrediting body. The number of URSI reports has gone down each year since 2019, when 144 were reported.

According to TJC’s annual review of its 2022 sentinel event data, what percentage of URSI's resulted in severe patient harm?

• 76%

• 20%

• 62%

• 40%

Answer explanation

Forty percent of the reported incidences resulted in severe patient harm, 35% required additional care or extended hospital stays, and 16% were characterized as “other/no harm. as “other/no harm.

What is the most commonly retained surgical instrument?

• Malleable

• Kocher

• Deaver

• Spongestick

Counting items and accounting for items during a procedure are the same process.

• True

• False

Answer explanation

The counting process is used to tally and track the number of a specific item used during a procedure (eg, 15 4x4 gauze sponges). Counting is recommended for selected items (eg, soft goods, sharps). Conversely, accounting for items is verifying that an item placed in the patient has been removed. Items that are accounted for may or may not be counted based on organizational policy and procedure (eg, a throat pack).

What is AORN's recommendation for counting surgical sponges?

• Manually

• Manually & using adjunct technology

• Manually, using adjunct technology, document on white board & count sheet

• Only count items that can fit within the cavity presently open

Caring for patients following RSI's increases the cost to health care systems by an estimated __________.

• $40,146

• $67,000

• $70,767

• $91,689

Answer explanation

The Centers for Medicare and Medicaid Services has not reimbursed health care systems for these costs since 2009, and facilities are often fined when RSI's occur.

The Joint Commission states that an unintended retention of a foreign object in a patient after an invasive procedure, including surgery, is a sentinel event. The Joint Commission defines “after surgery” as any time after the completion of final skin closure even if the patient is still in the procedural area or the operating room.

• True

• False

What are your Hard Stop CUS words?

• Concerned,

  Uncomfortable,

  Safety Issue

• Confused,

  Unannounced,

  Salty

• Concerned,

  Uncomfortable,

  Security

• Concerned,

  Upset,

  Safety Issue

According to the TJC, the leading causes of reported RSI's from June 2018 to 2022 included:

• Carelessness and distractions

• Cell phones and multiple procedures

• Communication issues and lack of adherence to facility policies

• Multiple procedures and lack of adherence to facility policies

Who should you notify should an intraoperative team member refuse to comply with a hard stop?

• The Joint Commission

• There is no need to notify anyone

• Mark Rubino

• Charge RN,

  Asst Manager,

  Manager,

  Educator

  Director