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More than 68,000 Americans died of opioid-involved overdose in 2020—a 37.6 percent increase over 2019, and the largest yearly increase in opioid-involved overdose deaths in two decades.^1,* A total of 16,416 (23.9 percent) of those deaths involved prescription opioids.¹ Approximately 21 to 29 percent of patients prescribed opioids for chronic pain misuse them,² and between 8 and 12 percent of patients prescribed opioids for chronic pain will develop an opioid use disorder (OUD).² It’s no surprise, then, that overdose death involving opioids is referred to as “a public health emergency” and an epidemic.^3,4

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, 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.

An unintended retained surgical item (RSI) is an item unintentionally left inside a patient¹ (in this case a surgical towel). Among surgical never events, 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.

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, 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.

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