Overview:

Unintentionally retained surgical items (URSIs) remain a significant patient safety concern and are recognized as both sentinel events and never events by national regulatory agencies.  URSIs are not solely a nursing issue; rather, they represent a complex, system-level challenge involving surgeons, anesthesia professionals, perioperative nurses, radiology personnel, and organizational leadership.

This educational program dives into the groundbreaking retrospective analysis conducted by the University of Michigan Health’s Perioperative Safety and Quality Improvement (PSQIP) team, using 4 years of RSI and miscount data from 1,537 intraoperative X-rays. Using real data from safety reports and EMR, along with surveys and interviews, the team can conduct cost analyses and identify where system breakdowns occur, creating concrete action plans to improve patient safety and OR efficiency.  In addition, the PSQIP team shares a step-by-step guide on how hospitals can easily pull their own data.  The program wraps up with an easy-to-follow framework for shifting the RSI and miscount workflow to regain trust among the perioperative team.  It is a practical and dynamic program for all OR nurses and leaders.