Presentation
Identifying Systemic Contributors to Retained Foreign Objects: Analysis of 1,352 Incidents Using the AcciMap Framework
DescriptionBackground. Medical errors are a leading cause of death in the United States and worldwide. Among adverse events in healthcare, retained foreign objects (RFOs) rank among the most frequently reported sentinel events according to The Joint Commission (TJC). This study analyzes the systemic, socio-technical causes of RFOs using real-world data. Like many adverse events, RFOs are not the result of isolated errors, but rather emerge from systemic weaknesses across multiple levels of the healthcare system. In investigating RFO cases specifically, only focusing on the count process and its accuracy is insufficient [1]; effective prevention requires stronger systemic defenses, process reviews, and cultural changes.
We examined 1,371 de-identified reports of unique RFO incidents submitted to TJC’s Office of Quality and Patient Safety between 2010 and the second quarter of 2020. Each incident was associated with multiple root causes, which were further categorized into subcategories with additional descriptive details. After excluding 19 non-surgical cases (e.g., dental-related incidents), 1,352 RFO events associated with surgical procedures remained for analysis. This study was reviewed by the Institutional Review Board (IRB) at California State University, Northridge and determined not to meet the regulatory definition of human subjects research, and was therefore exempt from IRB oversight.
Methods. The AcciMap framework was applied as a systems-based approach to analyze and identify socio-technical contributing causes underlying the 1,352 RFO incidents. Developed by Rasmussen in 1997 [2], AcciMap offers a hierarchical structure for understanding how decisions, actions, and conditions across multiple levels interact to shape safety outcomes. For this study, the context-specific layers of the framework, from top to bottom are: 1) government and regulatory bodies, 2) hospital, 3) surgery division management, 4) surgical staff, and 5) physical environment, work processes, and conditions in the operating room.
Unlike most applications of the AcciMap methodology, which analyze a single event or a small set of incidents, this study developed a framework based on 1,352 reported RFO cases. This large-scale, data-driven approach moves beyond case-specific mapping to reveal systemic vulnerabilities across a broad population. Our earlier work [3] also applied the AcciMap to analyze RFOs, but it relied on causes identified through literature review. By contrast, the present study is grounded in real-world data reported to TJC, making it a novel and significant advancement in both patient safety research and the methodological application of AcciMap.
Results. Our analysis of 1,352 RFO incidents reported to The Joint Commission revealed a broad set of socio-technical factors distributed across the five layers of the AcciMap framework. Across these layers, organizational shortcomings at the hospital level were especially dominant, with leadership failures, inadequate policies, and weak accountability mechanisms recurring in a majority of cases. At the management level, deficiencies in peer review, in-service education, and operative care planning created downstream vulnerabilities that influenced staff behavior and team performance. At the staff layer, communication breakdowns, procedural noncompliance, human factors such as fatigue and distraction, and inadequate assessment of patients and their records emerged as central contributors. Finally, at the work processes and environment level, poorly designed workflows, fragile task redundancies, and equipment or health IT failures added additional risk. Collectively, these results reinforce that RFOs are not isolated errors by individuals but rather products of systemic weaknesses that span multiple organizational layers.
To evaluate the relative weight of these factors, we applied a frequency-based analysis within the AcciMap framework. Each root cause category and its related subcategories were coded and aggregated by the number of cases in which they appeared. This method enabled the cross-layer comparison of influence. For instance, at the hospital layer, leadership issues were linked to 666 cases, making them by far the most prominent organizational-level contributor. Among these, the absence of relevant policies, procedures, and standards alone accounted for 575 cases (over 85% of leadership-related incidents). In the management layer, human factors such as failures in peer review (378 cases) and inadequate team training (204 cases) emerged as dominant drivers. At the staff level, communication breakdowns were implicated in nearly 1,200 cases, underscoring their centrality to frontline failures. By contrast, while equipment and physical environment issues were documented, their frequencies were substantially lower, suggesting they were contributory but not primary systemic drivers. This frequency-based approach provided a structured way to rank contributors and identify where systemic interventions may have the largest impact.
Analysis and Discussion. The AcciMap framework provides a uniquely powerful lens for understanding RFOs because it emphasizes how accidents emerge from dynamic interactions across a socio-technical system, rather than from isolated mistakes by individuals. By modeling causes across multiple levels—government, hospital, management, staff, and work processes—AcciMap captures both immediate precursors and the more distant systemic conditions that shape them. This holistic approach avoids over-attributing blame to frontline staff and instead highlights how organizational structures, resource constraints, cultural norms, and leadership decisions combine to create environments in which RFOs are more likely to occur.
A central strength of AcciMap is its upward tracking feature. This involves tracing contributing causes identified at the lowest level of the framework upward through higher levels to uncover their systemic origins. For example, a skipped surgical count at the staff layer may trace back to inadequate training at the management layer, which itself may be linked to resource constraints or absent policies at the hospital level. This form of analysis is invaluable because it not only identifies where errors occur but also reveals why they persist, pointing to organizational and structural leverage points for intervention. In our dataset, upward tracking repeatedly showed that frontline errors were reinforced by gaps in leadership accountability, ineffective policies, or weak safety culture at higher layers.
Our frequency-based evaluation method complemented this systemic mapping by providing quantitative indicators of influence. Ranking causes by recurrence allowed us to distinguish high-impact systemic drivers from lower-frequency issues. For instance, while inadequate lighting or noisy environments contributed to some incidents, these factors were far less frequent than communication breakdowns or failures to follow policies. This suggests that interventions targeting leadership accountability, standardized policies, and robust communication systems are likely to yield greater reductions in RFO occurrence risk than narrowly focusing on environmental fixes alone.
The integration of these methods—frequency analysis, upward tracking, and socio-technical mapping—provides both descriptive and practical insight. It shows that while immediate causes such as miscounts or communication errors occur at the staff level, they are often symptoms of systemic vulnerabilities at higher organizational layers. For example, inadequate credentialing or ineffective peer review processes not only compromise staff preparedness but also directly increase the likelihood of frontline errors. By surfacing these relationships, the AcciMap framework helps shift the focus of safety improvement efforts toward organizational policies, leadership culture, and structural design, which are more durable points of intervention.
Ultimately, our findings reinforce the need for multifaceted, system-wide strategies to prevent RFOs. Strengthening leadership safety values, ensuring consistent and team-based training, embedding redundancy into workflows, and improving communication infrastructures are critical steps. The evidence suggests that targeting these high-frequency, cross-cutting contributors will provide the greatest benefit in reducing RFO risk. The AcciMap approach thus not only clarifies how RFOs occur but also provides a roadmap for where interventions should be prioritized to achieve the most meaningful improvements in patient safety.
References
[1] Pennsylvania Patient Safety Advisory. Beyond the Count: Preventing Retention of Foreign Objects. 2009 June;6(2):39-45.
[2] Rasmussen J. Risk management in a dynamic society: A modelling problem. Safety Science. 1997;27(2-3):183-213.
[3] Tabibzadeh M, Patel Z. Reducing unintended retained foreign objects in operating rooms: a proactive risk assessment framework to improve patient safety. Journal of Patient Safety and Risk Management. 2021;27(1):26-41.
We examined 1,371 de-identified reports of unique RFO incidents submitted to TJC’s Office of Quality and Patient Safety between 2010 and the second quarter of 2020. Each incident was associated with multiple root causes, which were further categorized into subcategories with additional descriptive details. After excluding 19 non-surgical cases (e.g., dental-related incidents), 1,352 RFO events associated with surgical procedures remained for analysis. This study was reviewed by the Institutional Review Board (IRB) at California State University, Northridge and determined not to meet the regulatory definition of human subjects research, and was therefore exempt from IRB oversight.
Methods. The AcciMap framework was applied as a systems-based approach to analyze and identify socio-technical contributing causes underlying the 1,352 RFO incidents. Developed by Rasmussen in 1997 [2], AcciMap offers a hierarchical structure for understanding how decisions, actions, and conditions across multiple levels interact to shape safety outcomes. For this study, the context-specific layers of the framework, from top to bottom are: 1) government and regulatory bodies, 2) hospital, 3) surgery division management, 4) surgical staff, and 5) physical environment, work processes, and conditions in the operating room.
Unlike most applications of the AcciMap methodology, which analyze a single event or a small set of incidents, this study developed a framework based on 1,352 reported RFO cases. This large-scale, data-driven approach moves beyond case-specific mapping to reveal systemic vulnerabilities across a broad population. Our earlier work [3] also applied the AcciMap to analyze RFOs, but it relied on causes identified through literature review. By contrast, the present study is grounded in real-world data reported to TJC, making it a novel and significant advancement in both patient safety research and the methodological application of AcciMap.
Results. Our analysis of 1,352 RFO incidents reported to The Joint Commission revealed a broad set of socio-technical factors distributed across the five layers of the AcciMap framework. Across these layers, organizational shortcomings at the hospital level were especially dominant, with leadership failures, inadequate policies, and weak accountability mechanisms recurring in a majority of cases. At the management level, deficiencies in peer review, in-service education, and operative care planning created downstream vulnerabilities that influenced staff behavior and team performance. At the staff layer, communication breakdowns, procedural noncompliance, human factors such as fatigue and distraction, and inadequate assessment of patients and their records emerged as central contributors. Finally, at the work processes and environment level, poorly designed workflows, fragile task redundancies, and equipment or health IT failures added additional risk. Collectively, these results reinforce that RFOs are not isolated errors by individuals but rather products of systemic weaknesses that span multiple organizational layers.
To evaluate the relative weight of these factors, we applied a frequency-based analysis within the AcciMap framework. Each root cause category and its related subcategories were coded and aggregated by the number of cases in which they appeared. This method enabled the cross-layer comparison of influence. For instance, at the hospital layer, leadership issues were linked to 666 cases, making them by far the most prominent organizational-level contributor. Among these, the absence of relevant policies, procedures, and standards alone accounted for 575 cases (over 85% of leadership-related incidents). In the management layer, human factors such as failures in peer review (378 cases) and inadequate team training (204 cases) emerged as dominant drivers. At the staff level, communication breakdowns were implicated in nearly 1,200 cases, underscoring their centrality to frontline failures. By contrast, while equipment and physical environment issues were documented, their frequencies were substantially lower, suggesting they were contributory but not primary systemic drivers. This frequency-based approach provided a structured way to rank contributors and identify where systemic interventions may have the largest impact.
Analysis and Discussion. The AcciMap framework provides a uniquely powerful lens for understanding RFOs because it emphasizes how accidents emerge from dynamic interactions across a socio-technical system, rather than from isolated mistakes by individuals. By modeling causes across multiple levels—government, hospital, management, staff, and work processes—AcciMap captures both immediate precursors and the more distant systemic conditions that shape them. This holistic approach avoids over-attributing blame to frontline staff and instead highlights how organizational structures, resource constraints, cultural norms, and leadership decisions combine to create environments in which RFOs are more likely to occur.
A central strength of AcciMap is its upward tracking feature. This involves tracing contributing causes identified at the lowest level of the framework upward through higher levels to uncover their systemic origins. For example, a skipped surgical count at the staff layer may trace back to inadequate training at the management layer, which itself may be linked to resource constraints or absent policies at the hospital level. This form of analysis is invaluable because it not only identifies where errors occur but also reveals why they persist, pointing to organizational and structural leverage points for intervention. In our dataset, upward tracking repeatedly showed that frontline errors were reinforced by gaps in leadership accountability, ineffective policies, or weak safety culture at higher layers.
Our frequency-based evaluation method complemented this systemic mapping by providing quantitative indicators of influence. Ranking causes by recurrence allowed us to distinguish high-impact systemic drivers from lower-frequency issues. For instance, while inadequate lighting or noisy environments contributed to some incidents, these factors were far less frequent than communication breakdowns or failures to follow policies. This suggests that interventions targeting leadership accountability, standardized policies, and robust communication systems are likely to yield greater reductions in RFO occurrence risk than narrowly focusing on environmental fixes alone.
The integration of these methods—frequency analysis, upward tracking, and socio-technical mapping—provides both descriptive and practical insight. It shows that while immediate causes such as miscounts or communication errors occur at the staff level, they are often symptoms of systemic vulnerabilities at higher organizational layers. For example, inadequate credentialing or ineffective peer review processes not only compromise staff preparedness but also directly increase the likelihood of frontline errors. By surfacing these relationships, the AcciMap framework helps shift the focus of safety improvement efforts toward organizational policies, leadership culture, and structural design, which are more durable points of intervention.
Ultimately, our findings reinforce the need for multifaceted, system-wide strategies to prevent RFOs. Strengthening leadership safety values, ensuring consistent and team-based training, embedding redundancy into workflows, and improving communication infrastructures are critical steps. The evidence suggests that targeting these high-frequency, cross-cutting contributors will provide the greatest benefit in reducing RFO risk. The AcciMap approach thus not only clarifies how RFOs occur but also provides a roadmap for where interventions should be prioritized to achieve the most meaningful improvements in patient safety.
References
[1] Pennsylvania Patient Safety Advisory. Beyond the Count: Preventing Retention of Foreign Objects. 2009 June;6(2):39-45.
[2] Rasmussen J. Risk management in a dynamic society: A modelling problem. Safety Science. 1997;27(2-3):183-213.
[3] Tabibzadeh M, Patel Z. Reducing unintended retained foreign objects in operating rooms: a proactive risk assessment framework to improve patient safety. Journal of Patient Safety and Risk Management. 2021;27(1):26-41.
Event Type
Oral Presentations
TimeTuesday, March 243:50pm - 4:10pm EDT
LocationMurray Hill East
Patient Safety Research and Initiatives