Researchers analyzed data from 71 retained surgical item events between 2003 and 2009. Sixty-two percent of RSI procedures occurred on the day the patient was admitted to the hospital, and abdominal RSIs were most common
For retained item events, 50 of 71 involved team or system errors, and 37 of 71 involved intraoperative omission or variance of safety protocols. Less than 10 percent of RSI incidents were due to a single individual’s error.
Researchers suggested these findings may be important to preventing RSI procedures, which are “never events.”
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