Intended Retained Surgical Item (RSI) Not a Problem? Think Again!

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Intended Retained Surgical Item (RSI) – Not a Problem? Think Again!

As I was placing the last stitch of the skin closure on a total hip surgery, the tip of the needle broke off. To remove the 1-cm fragment, I would probably have to reopen part of the skin incision (which could increase the risk of prosthetic joint infection), would possibly have to convert from spinal to general anesthetic, and there would be additional radiation exposure for the patient. I had intended to leave the fragment, but the hospital where I practice informed me that I HAD to remove it prior to the patient leaving the OR. It made no difference to the hospital whether this was a broken drill bit, a needle fragment or any other RSI. I subsequently had to answer to the hospital’s Peer Review Committee.

Suggestions based upon my experience:

  1. Review the information presented through an excellent summary of the topic of RSIs by Verna C. Gibbs, MD.1
  2. Be aware of your hospital’s current policy on RSIs, because each hospital can interpret the rules of the Joint Commission and National Quality Forum differently.2, 3
  3. Be prepared to act accordingly the next time you encounter an RSI.

Jeffrey M. Nakano, MD
[email protected]


    (Appendix A, page A-4)

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