International Journal of Research and Scientific Innovation (IJRSI)
Retained Surgical Items as Emergent Systems Failure: An Integrated Multi-Theory Prevention Framework for Perioperative Settings
Published June 17, 2026 • Vol. 13, Issue 5, pp. 3307–3319Open Access
DOI: 10.51244/IJRSI.2026.1305000283
Abstract
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.
Keywords: Retained surgical item; never event; psychological safety; Swiss Cheese Model
| Journal | International Journal of Research and Scientific Innovation (IJRSI) |
|---|---|
| ISSN | 2321-2705 |
| Volume / Issue | Volume 13, Issue 5 |
| Pages | 3307–3319 |
| Publication date | June 17, 2026 |
| DOI | 10.51244/IJRSI.2026.1305000283 |
| Publisher | RSIS International |
| License | Open Access |
How to cite this article
Dr Shoeb Ahmed Ilyas, & Ayesha Ahmed Ilyas (2026). Retained Surgical Items as Emergent Systems Failure: An Integrated Multi-Theory Prevention Framework for Perioperative Settings. International Journal of Research and Scientific Innovation (IJRSI), 13(5), 3307-3319. https://doi.org/10.51244/IJRSI.2026.1305000283
BibTeX
@article{Dr2026,
title = {Retained Surgical Items as Emergent Systems Failure: An Integrated Multi-Theory Prevention Framework for Perioperative Settings},
author = {Dr Shoeb Ahmed Ilyas and Ayesha Ahmed Ilyas},
journal = {International Journal of Research and Scientific Innovation (IJRSI)},
volume = {13},
number = {5},
pages = {3307--3319},
year = {2026},
doi = {10.51244/IJRSI.2026.1305000283},
publisher = {RSIS International}
}