Retained
surgical items (RSI) - instruments, sponges and needles inadvertently left in various body spaces after an operation
- have been a problem since the practice of surgery began. It has been estimated that at least 1500-2000 cases occur each
year in the United States. These cases represent problems in communication between perioperative care personnel
(Surgeons, Nurses, Radiologists) and problems in perioperative processes of care (examination of the surgical wound,
accounting procedures for surgical items, x-ray interpretation).
The RSI can be discovered hours to years
after the initial operation and a second operation is usually required to remove the retained object. A RSI case is a "canary
in the coal mine" and is reflective of system problems in the OR. It is rarely the result of a single individual error - thus
blaming individuals will not lead to problem resolution. Changes in the systems of OR care are required to prevent this event
from happening. System fixes require multi-stakeholder input.
NoThing Left Behind is an initiative introduced
in January 2005. We work to get multiple healthcare stakeholders together to make sure RSI become a "never event". The goal
is the develop and disseminate evidence and experience-based practices that will prevent RSI. We have worked with hospitals
around the country in redesigning their policies, improving OR processes
of care and evaluating new technology being developed to account for surgical items. We work with members of the legal community
and risk managers to provide better counsel. We work with the business community in the refinement and development of safe
and reliable products.
We will measure success by getting cases
of RSI in all hospitals to zero by 2010. With effective perioperative care systems
the surgical patient can be assured that there will be "NoThing Left Behind".
