Project Intermediate Manager University of Michigan Health
Presentation Time:
Monday, 4/13/2026: 10:30-11:15am
Unintentionally retained surgical items (URSIs) remain a significant patient safety concern and are recognized as both sentinel events and never events by national regulatory agencies. URSIs are not solely a nursing issue; rather, they represent a complex, system-level challenge involving surgeons, anesthesia professionals, perioperative nurses, radiology personnel, and organizational leadership. Contributing factors include workflow inefficiencies, variability in policy adherence, increasing procedural complexity, equipment variability, provider fatigue, and time pressures within the perioperative environment. This educational program examines traditional URSI prevention strategies, such as manual surgical counts and intraoperative radiography, while also highlighting evidence-based adjunct technologies. Central to this discussion is the role of data-driven root cause analysis in identifying local risk patterns and implementing targeted interventions to reduce URSI incidence and enhance perioperative patient safety.
Learning Objectives:
Define retained surgical items (RSIs) and describe unintentionally RSIs (URSIs) as preventable patient safety events
Explain why manual counts are not sufficient in preventing URSI and describe the miscounts on the patient, perioperative personnel, and the organization
Recognize individual and team-based perceptions, behaviors, and cognitive factors that increase the risk of URSIs in the perioperative environment
Analyze an organization’s risk for URSIs and apply quality improvement methods to develop and evaluate system-level strategies and tactics aimed at reducing URSI risk
Explain the role of adjunct technologies and describe how these tools may be used in conjunction with manual counting and radiographic imaging when an URSI is suspected
