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PSNet: Patient Safety Network
Journal Article
Study

Rates of serious surgical errors in California and plans to prevent recurrence.

Cohen AJ, Lui H, Zheng M, et al. JAMA Netw Open. 2021;4(5):e217058.

While rare, surgical never events can have tragic consequences for patients including permanent harm and death. This study analyzed 142 surgical never events reported to the California Department of Public Health. Retained foreign objects were the most commonly reported never event (66.2%), followed by wrong site or wrong patient (15.5%), and surgical burns (7.7%). Recommended strategies to reduce and prevent never events include proper use of intraoperative checklists.