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The reporting of unusual occurrences and adverse events has been a staple of the risk management plan in hospitals and healthcare facilities for many years. Incident and event reports, whether written or oral, are a means of alerting hospital leaders to potential or actual patient harm. These reports are critical to the ongoing identification of risk and the investigation of the circumstances that led to an adverse event. The reports, too, are key to the development of risk mitigation strategies designed to create a safer environment for patients, physicians, and staff. Additionally, the incident report, and the information it contains, is a valuable alert to potentially compensable events and the need for disclosure discussions.

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.