Access Now: Transmission Precautions for Monkeypox Infection

AORN Center of Excellence in Surgical Safety: Prevention of RSI

AORN is proud to introduce a new complimentary education and recognition program for perioperative teams.

This evidence-based education raises awareness of factors that lead to RSIs, uses scenario-based immersive technology to improve skills, and helps teams mitigate risks and improve outcomes.

Your facility can earn public recognition and confirm your commitment to the highest levels of patient safety as an AORN Center of Excellence in Surgical Safety: Prevention of RSI after completing the program’s training.

What You Will Learn

This program is optimized to adult-learning styles with real-time feedback to test comprehension.

You and your team will learn:

  • Evidence-based human behaviors and environmental influences that lead to unintended RSI.
  • Procedures for accurately counting surgical items.
  • Strategies to increase compliance with counting processes before, during, and after procedures.
  • Guidelines for reconciling discrepancies, including the use of adjunct technologies to augment manual counts.

Ready to take action against RSI?

Log in today or create a free AORN account.


Surgeon and nurses working during surgery.


$525,000 estimated cost of an RSI. 
RSIs occur in 1 per 10,000 surgical procedures. 
Only 67% of RSIs are detected by x-rays. 

Program Components

  • Pre-Test
  • Eight Education Modules featuring three scenario-based escape rooms!
    1. Overview
    2. Interdisciplinary Approach
    3. Standard Procedure
    4. Soft Goods, Sharps, and Instruments
    5. Device Fragments
    6. Reconciling Count Discrepancies
    7. Adjunct Technology
    8. Human Factors
  • Post-Test
  • Process Audits
  • Recognition Application

Download a complimentary gap analysis tool to assess current RSI prevention practices.


Ready to take action against RSIs? Register now.

Benefits of the Program

  • Aid in reducing or eliminating this sentinel event.
  • Foster a collaborative work environment.
  • Decrease costs associated with retained surgical items.
  • Gain community and national recognition as a Center of Excellence in Surgical Safety.
  • Prevent near misses.

Want to learn more?


Need more information or assistance? Contact [email protected]

Periop nurses counting sponges post-surgery. 
Periop nurse counting sponges pre-surgery. 
Nurse wearing scrubs in a surgical room. 


Cost associated with RSI

  • Williams TL, Tung DK, Steelman VM, Chang PK, Szekendi MK. Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology. J Am Coll Surg. 2014;219(3):354-364.
  • Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent recurrence. JAMA Netw Open. 2021;4(5):e217058.
  • Blanchfield BB, Acharya B, Mort E. The hidden costs of regulation: the administrative cost of reporting serious reportable events. Jt Comm J Qual Patient Saf. 2018;44(4):212-218.


  • Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80-87

1 per 10,000 Procedures

  • Guideline for prevention of unintentionally retained surgical items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2022:827-894.

Stryker            AORN Foundation