Exclusive: How surgical miscounts expose fragile safety nets

Retained surgical items (RSIs) remain among the most preventable yet persistently recurring surgical “never events.” Despite decades of implementing process checklists, counting protocols, and technology solutions, surgical items continue to be left inside patients across the country.

The University of Michigan Health’s Periprocedural Safety and Quality Improvement (PSQIP) team says the question “How do RSIs happen?” is no longer sufficient. Instead, it asked this question: “How, where, and why are our safety nets failing us?”

In this exclusive article for OR Manager, take a deep dive with the PSQIP team’s analysis and learn what its findings reveal about counting discrepancies, imaging decisions, and opportunities to strengthen patient safety in the operating room.