Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Hamid R. Zahiri; Jeffrey Stromberg; Hadas Skupsky; Erin K. Knepp; Matthew Folstein; Ronald Silverman; Devinder Singh

Review

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

April 4, 2011

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18(1):55-60.

View more articles from the same authors.

This review summarizes the epidemiology and common etiology of three types of surgical never events and makes recommendations to prevent such incidents.

PubMed citation

Available at

Related Resources From the Same Author(s)

Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology.

February 10, 2012

Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events.

May 25, 2022

Wrong-site surgery in California, 2007–2014.

September 13, 2017

From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system.

March 24, 2017

Creating an integrated patient safety team.

January 5, 2017

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Effect of genetic diagnosis on patients with previously undiagnosed disease.

March 19, 2019

Effect of digital tools to promote hospital quality and safety on adverse events after discharge.

July 31, 2024

Changes in medical errors after implementation of a handoff program.

November 12, 2014

A Department of Medicine infrastructure for patient safety and clinical quality improvement.

August 8, 2018

Related Resources

Identifying resilience: a system safety review of trauma and orthopaedic theatres.

November 6, 2024

Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix.

June 12, 2024

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

October 25, 2023

Common general surgical never events: analysis of NHS England never event data.

April 7, 2021

Preventing unintended retained foreign objects.

December 23, 2016

Advancing Patient Safety in Cataract Surgery: A Betsy Lehman Center Expert Panel Report.

June 15, 2016

Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events.

May 26, 2016

Incorrect surgical procedures within and outside of the operating room.

April 30, 2014

The recurring problem of retained swabs and instruments.

July 16, 2013

Surgical never events in the United States.

April 17, 2013

See More About The Topic

Operating Room

Health Care Providers

Quality and Safety Professionals

Surgery

Retained Surgical Instruments and Sponges

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site

Submit Your Training

Continue as a Guest

Continue Logged In

Submit Your Training

Continue as a Guest

Continue Logged In

New Users to the PSNet site

Submit Your Toolkit

Continue as a Guest

Continue Logged In

Submit Your Toolkit

Continue as a Guest

Continue Logged In

New Users to the PSNet site

Submit Your WebM&M Case

Continue as a Guest

Continue Logged In

Submit Your WebM&M Case

Continue as a Guest

Already have a PSNet

Account?

New Users