Retained Surgical Items as Emergent Systems Failure: An Integrated Multi-Theory Prevention Framework for Perioperative Settings

Background. Retained surgical items (RSIs) are classified as Never Events, yet they persist despite the WHO Surgical Safety Checklist, AORN counting standards, and commercial radio-frequency identification (RFID) systems. The Joint Commission logged 119 RSI sentinel events in 2024, with 43% causing severe harm, a pattern more consistent with system pathology than individual lapse.
Objective. To develop the Integrated RSI Prevention Architecture (IRPA): a conceptual framework explaining RSI occurrence as the emergent product of simultaneous failure across cultural, human-factor, technological, and governance domains.

Retained surgical item; never event; psychological safety; Swiss Cheese Model

1. Carayon, P. A. S. H., Hundt, A. S., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Brennan, P. F. (2006). Work system design for patient safety: the SEIPS model. BMJ Quality & Safety, 15(suppl 1), i50-i58. [Google Scholar] [Crossref]

2. Carmack, A., Valleru, J., Randall, K., Baka, D., Angarano, J., & Fogel, R. (2023). A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items. The Joint Commission Journal on Quality and Patient Safety, 49(1), 3–13. [Google Scholar] [Crossref]

3. De Vries, E. N., Ramrattan, M. A., Smorenburg, S. M., Gouma, D. J., & Boermeester, M. A. (2008). The incidence and nature of in-hospital adverse events: a systematic review. BMJ Quality & Safety, 17(3), 216–223. [Google Scholar] [Crossref]

4. de Vries, E. N., Prins, H. A., Crolla, R. M., den Outer, A. J., van Andel, G., van Helden, S. H., ... & Boermeester, M. A. (2010). Effect of a comprehensive surgical safety system on patient outcomes. New England Journal of Medicine, 363(20), 1928-1937. [Google Scholar] [Crossref]

5. Dekker, S. (2016). Drift into failure: From hunting broken components to understanding complex systems. CRC Press. [Google Scholar] [Crossref]

6. Edmondson, A. (1999). Psychological safety and learning behaviour in work teams. Administrative Science Quarterly, 44(2), 350–383. [Google Scholar] [Crossref]

7. Etheridge, J. C., Moyal-Smith, R., Yong, T. T., Lim, S. R., Sonnay, Y., Lim, C., ... & Havens, J. M. (2024). Transforming team performance through reimplementation of the surgical safety checklist. JAMA Surgery, 159(1), 78–86. [Google Scholar] [Crossref]

8. Frazier, M. L., Fainshmidt, S., Klinger, R. L., Pezeshkan, A., & Vracheva, V. (2017). Psychological safety: A meta‐analytic review and extension. Personnel psychology, 70(1), 113–165. [Google Scholar] [Crossref]

9. Greenberg, C. C., Regenbogen, S. E., Studdert, D. M., Lipsitz, S. R., Rogers, S. O., Zinner, M. J., & Gawande, A. A. (2007). Patterns of communication breakdowns resulting in injury to surgical patients. Journal of the American College of Surgeons, 204(4), 533–540. [Google Scholar] [Crossref]

10. Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. H. S., Dellinger, E. P., ... & Gawande, A. A. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. New England journal of medicine, 360(5), 491–499. [Google Scholar] [Crossref]

11. Hollnagel, E. (2018). Safety-I and safety-II: the past and future of safety management. CRC Press. [Google Scholar] [Crossref]

12. Jaakkola, E. (2020). Designing conceptual articles: four approaches. AMS review, 10(1), 18–26. [Google Scholar] [Crossref]

13. James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122–128. [Google Scholar] [Crossref]

14. Donaldson, M. S., Corrigan, J. M., & Kohn, L. T. (Eds.). (2000). To err is human: building a safer health system. [Google Scholar] [Crossref]

15. Makary, M. A., & Daniel, M. (2016). Medical error is the third leading cause of death in the US. BMJ, 353. [Google Scholar] [Crossref]

16. May, C., & Finch, T. (2009). Implementing, embedding, and integrating practices: an outline of normalisation process theory. Sociology, 43(3), 535–554. [Google Scholar] [Crossref]

17. Neily, J., Mills, P. D., Young-Xu, Y., Carney, B. T., West, P., Berger, D. H., ... & Bagian, J. P. (2010). Association between implementation of a medical team training program and surgical mortality. Jama, 304(15), 1693-1700. [Google Scholar] [Crossref]

18. Newman, A., Donohue, R., & Eva, N. (2017). Psychological safety: A systematic review of the literature. Human resource management review, 27(3), 521–535. [Google Scholar] [Crossref]

19. Pronovost, P., Needham, D., Berenholtz, S., Sinopoli, D., Chu, H., Cosgrove, S., ... & Goeschel, C. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. New England journal of medicine, 355(26), 2725–2732. [Google Scholar] [Crossref]

20. Reames, B. N., Krell, R. W., Campbell Jr, D. A., & Dimick, J. B. (2015). A checklist-based intervention to improve surgical outcomes in Michigan: evaluation of the Keystone Surgery program. JAMA Surgery, 150(3), 208–215. [Google Scholar] [Crossref]

21. Reason, J. (1990). Human error. Cambridge University Press. [Google Scholar] [Crossref]

22. Reason, J. (2016). Managing the risks of organisational accidents. Routledge. [Google Scholar] [Crossref]

23. Schmutz, J., & Manser, T. (2013). Do team processes really have an effect on clinical performance? A systematic literature review. British Journal of Anaesthesia, 110(4), 529–544. [Google Scholar] [Crossref]

24. Shojania, K. G., & Dixon-Woods, M. (2017). Estimating deaths due to medical error: the ongoing controversy and why it matters. BMJ Quality & Safety, 26(5), 423–428. [Google Scholar] [Crossref]

25. Stawicki, S. P., Moffatt-Bruce, S. D., Ahmed, H. M., Anderson III, H. L., Balija, T. M., Bernescu, I., ... & Cook, C. H. (2013). Retained surgical items: a problem yet to be solved. Journal of the American College of Surgeons, 216(1), 15–22. [Google Scholar] [Crossref]

26. The Joint Commission. (2024). Sentinel event data summary. https://digitalassets.jointcommission.org/api/public/content/eac7511986c0442a9c1ae04b1aa02cc0?v=ad34daa0 [Google Scholar] [Crossref]

27. Urbach, D. R., Govindarajan, A., Saskin, R., Wilton, A. S., & Baxter, N. N. (2014). Introduction of surgical safety checklists in Ontario, Canada. New England Journal of Medicine, 370(11), 1029–1038. [Google Scholar] [Crossref]

28. Weick, K. E., Sutcliffe, K. M., & Obstfeld, D. (1999). Organising for High Reliability: Processes of Collective Mindfulness, Research in Organisational Behaviour. Research in Organisational Behaviour, 1, 81–123. [Google Scholar] [Crossref]

29. World Health Organization. (2021). Global patient safety action plan 2021-2030: towards eliminating avoidable harm in health care. World Health Organization. [Google Scholar] [Crossref]

• Treasure of 6th Edition of Organon of Medicine- Lm Potency
• Neurobehavioral and Immune-Histochemical Effects of Daucus Carota Ethanolic Leaf Extract in Cadmium-Induced Toxicity of the Hippocampus and Prefrontal Cortex of Adult Wistar Rats
• Unveiling the Antimicrobial Potential of Homoeopathic Sarcode and Bowel Nosode: A Study on Histaminum and Dysenteriae Co against Escherichia Coli And Klebsiella Bacteria
• Incidence of Cardiovascular Events in Patients Receiving Hematopoietic Stem Cell Transplant (HSCT) in HCTM – (A Retrospective Cohort Study)
• A Prospective Case Study Examining the Effectiveness of Homoeopathic Medicine in Treating Degenerative Changes in the Lumbar Spine-A Case Report