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Related Experiment Video

Updated: Sep 13, 2025

A Simplified Technique for Producing an Ischemic Wound Model

A Simplified Technique for Producing an Ischemic Wound Model

Published on: May 2, 2012

Using SEIPS 101 Tools to Model Surgical Count Processes.

Julia Meilan¹, Connor Lusk¹, Elizabeth K Galinsky²

¹Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina.

Journal of Patient Safety

|July 25, 2025

Summary

This summary is machine-generated.

Understanding surgical counting systems factors is crucial for preventing retained foreign objects (RFOs). This study used SEIPS 101 tools to map the complex interactions of people, tasks, and tools, revealing numerous barriers and facilitators to RFO prevention.

Keywords:

RFO prevention Systems Engineering Initiative for Patient Safety (SEIPS) 101 retained foreign objects (RFOs)surgical count process the surgical count

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Last Updated: Sep 13, 2025

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Area of Science:

Patient Safety
Surgical Process Improvement
Systems Engineering in Healthcare

Background:

Retained foreign objects (RFOs) are a significant patient safety concern.
Surgical counts are the primary method for RFO prevention.
Limited research exists on the system factors influencing surgical counts.

Purpose of the Study:

To develop SEIPS 101 tools for analyzing system factors in surgical counts.
To better understand the contributing factors to retained foreign objects (RFOs).

Main Methods:

Direct observation of surgical count processes in 22 cases.
In situ interviews during iterative tool development.
Utilized journey maps, people maps, task-tool matrices, and PETT scans.

Main Results:

Identified 6 phases, 4 environments, and 3 team members in the counting process.
Revealed 8 influential people and complex communication needs.
Found 4 high-frequency tools with usability challenges.
Documented 56 barriers and 31 facilitators to the count process.

Conclusions:

Surgical counting involves complex system interactions beyond simple adherence to policy.
Resilience and adaptive behaviors play a hidden role in RFO prevention.
Findings challenge traditional explanations for RFOs and suggest new intervention strategies.