Presented By: Verna C. Gibbs, M.D.
September 2018

Following up on January’s presentation on the three surgical safety never events – retained surgical items (RSI), surgical fires and wrong-site surgery – in March we took an indepth look at the problem of the second most common RSI – the Small Miscellaneous Items (SMIs) and Unretrieved Device Fragments (UDFs). Reviewing information obtained through the NoThing Left Behind^® Surgical Safety Project to Prevent RSI, increased reports of retention of a panoply of surgical material as well as bits and pieces of surgical equipment which are retrieved or ultimately are determined to be UDFs are available. Events of retention occur throughout the medical center so it’s not just from the ORs. SMIs and UDFs can cause patient harm and we are increasingly seeing that the “risk of removal actually is not greater than the risk of retention”. Once clinicians have a greater understanding of the important elements of this problem, they frequently make efforts to remove these items and more importantly, everyone begins to work together to prevent retention in the first place.

Objectives:

• Define the taxonomy used for clearly reporting RSI, Device and UDF events
• Outline multi-stakeholder practice and communication strategies for prevention of retained SMIs
• Collect the right information when an event occurs
• Perform proper disclosure activities