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

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.