---
title: Resource Library | Case Study (2)
description: Case Study | The Resource Library offers a broad spectrum of resources and actionable insights to help you manage your healthcare business, increase patient safety, and help your practice thrive. (2)
---

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# [Resource Library](https://www.norcal-group.com/library)

## [Surgical Never Event - Retained Needle](https://www.norcal-group.com/library/surgical-never-event-retained-needle)

 January 30, 2023

[![](https://files.norcal-group.com/hubfs/surgical-team-preparing-for-surgery-1421626444_soc.jpg) ](https://www.norcal-group.com/library/surgical-never-event-retained-needle)

An unintended retained surgical item (RSI) is an item unintentionally left inside a patient (e.g., sponges, towels, device components, guidewires, needles, and instruments).1 Among [surgical never events](https://www.norcal-group.com/library/preventing-surgical-never-events-case-studies-and-best-practices), RSI is the most frequently reported to the Joint Commission.2 According to the Joint Commission, the most common causes of RSIs include the absence of policies and procedures, failure to comply with existing policies and procedures, and inadequate or incomplete staff education.3 NORCAL Group (now part of ProAssurance) closed claims involving an RSI often involve reporting of correct counts or completed surgeries, despite knowledge of an incorrect count. The following case illustrates an example of how and why RSIs occur.

[Learn More »](https://www.norcal-group.com/library/surgical-never-event-retained-needle) 

 Filed under: [Case Study](https://www.norcal-group.com/library/topic/case-study), [Practice Manager](https://www.norcal-group.com/library/topic/practice-manager), [Physician](https://www.norcal-group.com/library/topic/physician), [Patient Care](https://www.norcal-group.com/library/topic/patient-care), [Claims Rx](https://www.norcal-group.com/library/topic/claims-rx), [never event](https://www.norcal-group.com/library/topic/never-event), [culture of safety](https://www.norcal-group.com/library/topic/culture-of-safety)

## [Surgical Never Event - Retained Surgical Towel](https://www.norcal-group.com/library/surgical-never-event-retained-surgical-towel)

 January 30, 2023

[![](https://files.norcal-group.com/hubfs/worried-surgeon-in-an-operating-room_soc.jpg) ](https://www.norcal-group.com/library/surgical-never-event-retained-surgical-towel)

An unintended retained surgical item (RSI) is an item unintentionally left inside a patient1 (in this case a surgical towel). Among [surgical never events](https://www.norcal-group.com/library/preventing-surgical-never-events-case-studies-and-best-practices), RSI is the most frequently reported to the Joint Commission.2 As in this case, NORCAL Group (now part of ProAssurance) closed claims involving RSIs often involve reporting of correct counts or completed surgeries, despite knowledge of an incorrect count.

[Learn More »](https://www.norcal-group.com/library/surgical-never-event-retained-surgical-towel) 

 Filed under: [Case Study](https://www.norcal-group.com/library/topic/case-study), [Practice Manager](https://www.norcal-group.com/library/topic/practice-manager), [Physician](https://www.norcal-group.com/library/topic/physician), [Patient Care](https://www.norcal-group.com/library/topic/patient-care), [Claims Rx](https://www.norcal-group.com/library/topic/claims-rx), [never event](https://www.norcal-group.com/library/topic/never-event), [culture of safety](https://www.norcal-group.com/library/topic/culture-of-safety)

## [Surgical Never Event - Retained Lap Pad](https://www.norcal-group.com/library/surgical-never-event-retained-lap-pad)

 January 30, 2023

[![](https://files.norcal-group.com/hubfs/surgeons-working-in-operating-room-151811787_soc.jpg) ](https://www.norcal-group.com/library/surgical-never-event-retained-lap-pad)

An unintended retained surgical item (RSI) is an item unintentionally left inside a patient (e.g., sponges, towels, device components, guidewires, needles, and instruments).1 Among [surgical never events](https://www.norcal-group.com/library/preventing-surgical-never-events-case-studies-and-best-practices), RSI is the most frequently reported to the Joint Commission.2 Surgical sponges are the most commonly reported retained item.3 According to the Joint Commission, the most common causes of RSIs include the absence of policies and procedures, and inadequate or incomplete staff education, and failure to comply with existing policies and procedures,4 as we see in this case.

[Learn More »](https://www.norcal-group.com/library/surgical-never-event-retained-lap-pad) 

 Filed under: [Case Study](https://www.norcal-group.com/library/topic/case-study), [Practice Manager](https://www.norcal-group.com/library/topic/practice-manager), [Physician](https://www.norcal-group.com/library/topic/physician), [Patient Care](https://www.norcal-group.com/library/topic/patient-care), [Claims Rx](https://www.norcal-group.com/library/topic/claims-rx), [never event](https://www.norcal-group.com/library/topic/never-event), [culture of safety](https://www.norcal-group.com/library/topic/culture-of-safety)

## [Surgical Never Event - Surgery on the Wrong Knee](https://www.norcal-group.com/library/surgical-never-event-surgery-on-the-wrong-knee)

 January 30, 2023

[![](https://files.norcal-group.com/hubfs/doctor-and-nurse-medical-team-are-performing-surgical-operation-1332985409_soc.jpg) ](https://www.norcal-group.com/library/surgical-never-event-surgery-on-the-wrong-knee)

Wrong-site surgery incidents are usually due to multiple processes that combine to cause the event, as opposed to one specific error.

[Learn More »](https://www.norcal-group.com/library/surgical-never-event-surgery-on-the-wrong-knee) 

 Filed under: [Case Study](https://www.norcal-group.com/library/topic/case-study), [Practice Manager](https://www.norcal-group.com/library/topic/practice-manager), [Physician](https://www.norcal-group.com/library/topic/physician), [Patient Care](https://www.norcal-group.com/library/topic/patient-care), [Claims Rx](https://www.norcal-group.com/library/topic/claims-rx), [never event](https://www.norcal-group.com/library/topic/never-event), [culture of safety](https://www.norcal-group.com/library/topic/culture-of-safety)

## [Preventing Surgical Never Events - Case Studies and Best Practices](https://www.norcal-group.com/library/preventing-surgical-never-events-case-studies-and-best-practices)

 January 30, 2023

[![](https://files.norcal-group.com/hubfs/surgeons-in-operating-room-539282287_soc.jpg) ](https://www.norcal-group.com/library/preventing-surgical-never-events-case-studies-and-best-practices)

*Never event* was coined in 2001 to describe medical errors that should never happen. The National Quality Forum (NQF) now lists 29 types of never events1 (also referred to as “serious reportable events” by NQF and “sentinel events” by The Joint Commission). The linked case studies address examples of surgical adverse incidents that would be considered never events: retained surgical items, surgical fires, and wrong-site surgery.

[Learn More »](https://www.norcal-group.com/library/preventing-surgical-never-events-case-studies-and-best-practices) 

 Filed under: [Case Study](https://www.norcal-group.com/library/topic/case-study), [Practice Manager](https://www.norcal-group.com/library/topic/practice-manager), [Physician](https://www.norcal-group.com/library/topic/physician), [Patient Care](https://www.norcal-group.com/library/topic/patient-care), [Claims Rx](https://www.norcal-group.com/library/topic/claims-rx), [never event](https://www.norcal-group.com/library/topic/never-event), [culture of safety](https://www.norcal-group.com/library/topic/culture-of-safety)

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