Multi-Disciplinary RSI Reduction — New AORN Recommended Practices

Surgical-safety events usually are caused by problems with the way we do things (practices) and how we share knowledge and information about what we want to do (communication). No surprise that this is true for retained surgical items (RSIs).1 To date, surgical sponges have been the most common RSI2 and we have the most information about these types of cases.

If we study experiential evidence (root-cause analyses, focused reviews and event reports), we find that in approximately 80 percent of operating room (OR) cases when a retained surgical sponge was discovered hours, days, weeks, months or years later, the surgical team recorded the sponge count as correct at the end of the operation. (This excludes cases of retained vaginal sponges after a spontaneous vaginal birth, cases where sponges were intentionally left in for therapeutic packing or cases where the patient was too sick to continue an operation.) This is referred to as correct count retention cases (CCRCs) even though the after-event analysis revealed that the “correct” count was wrong. In 20 percent of cases where a retained surgical sponge was reported, the final count was recorded as incorrect. That is, at the end of the operation the surgical team knew they were missing a sponge, yet the patient still left the OR with the sponge inside his/her body. This is referred to as incorrect count retention cases (ICRCs).

Even though the end result in both types of cases is a retained sponge, the causes of retention are different. In CCRCs, the primary problem is usually with OR practices related to the way in which the sponges are accounted (or not), while in ICRCs, the team knows there is a missing surgical item (MSI), but there are usually problems with communication. The surgeons, anesthesiologists, nurses and surgical technologists all have practice problems in CCRCs, and the surgeons, nurses, surgical technologists, radiologists and radiology technologists have knowledge and information problems in ICRCs. It may be that there are also some practice problems in ICRCs, but communication failures predominate, and similarly there are probably communication failures in CCRCs, but problems with OR practices of sponge removal and counting predominate. So, to prevent RSIs, practice change, knowledge and shared information between multi-disciplinary perioperative personnel are required.3

In July 2010, the Association of periOperative Registered Nurses (AORN), the recognized leading organization of OR nurses, published a new version of one of its Recommended Practices (RPs).4 RPs are guidelines that have historically formed the foundation upon which all hospitals with ORs and procedural areas base their policies. The former RP, titled “Counts,” has been renamed “Prevention of Retained Surgical Items” and covers safety thinking, environmental control issues and new considerations for miscellaneous items and device fragments, and adjunct sponge management technology. Most importantly, AORN recognizes that a multi-disciplinary approach to prevention of RSIs is required. AORN received input from the American College of Surgeons and the American Association of Anesthesiologists, and has generated an excellent, far-reaching and comprehensive set of team management guidelines to help hospitals. The RP includes actions that should be incorporated into hospital OR policies, for nurses, surgical technologists, surgeons, anesthesiologists, radiologists, radiology technologists and risk managers. Hospitals will have to move beyond “count policies” and toward the development of multi-stakeholder OR policies for the prevention of RSIs.

For a copy of the RP, go to After reading it, continue to engage hospital staff and medical staff who must work together to ensure patients leave the OR with “NoThing Left Behind.”


1. Gibbs VC. Patient safety practices in the operating room: correct-site surgery and nothing left behind. Surg Clin North Am. 2005;85:1307.

2. Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbord C et al. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207;80.

3. Gibbs VC, Coakley RD, Reines HD. Preventable errors in the operating room: retained foreign bodies after surgery — part 1. Curr Probl Surg. 2007;44:281.

4. AORN, Perioperative Standards and Recommended Practices, July 2010, online at: