Surgical never events are rare but devastating for patients. Using machine learning, this study identified 24 contributing factors to two types of surgical never events - wrong site surgery and retained items. Communication, the number and type of staff present, and the type and length of surgery were identified contributing factors.

AORN revised its Guideline for prevention of unintentionally retained surgical items in late 2021. This article focuses on concepts and recommendations specific to counting procedures, reconciling discrepancies, technology, and education.

Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.

Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.

A retained foreign object can lead to serious clinical consequences and is considered a never event. Researchers analyzed a national patient safety incident database to identify factors contributing to guidewire retention and potential preventative measures. Findings indicate that most retained guidewires are identified after the procedure. The authors suggest that system changes or design modifications to central venous catheter equipment is one approach to prevent guidewire attention.

Retained surgical items (RSI) are a never event, yet they continue to happen. This commentary summarizes recent changes to an existing guidance that defines a range of retained devices or products to coalesce with industry terminology. The author shares steps to reduce the potential for RSI retention. 

Hospitals have implemented radiofrequency identification (RFID) technology to improve patient safety. This systematic review of 5 studies suggests that use of RFID can lead to rapid, accurate detection of retained surgical instruments (RSIs) and reduced risk of counting errors.

Unintentionally retained foreign objects (RFO) following surgery is a never event. In this study, researchers observed 36 surgical procedures to quantify and describe interruptions and distractions present during surgical counting. Interruptions (e.g., the surgeon or another nurse talking to the scrub nurse) and distractions (e.g., music, background noise) were common. Several suggestions to minimize interruptions and distractions during surgical counts are made.

A retained surgical sharp (RSS) is a never event. Operating room (OR) team members, including surgeons, anesthesiologists, and nurses, were surveyed regarding their experiences with actual and near-miss sharps (NMS). While nearly all team members reported experiencing at least one RSS or NMS in the past year, responses to other survey items varied by professional group. Surgeons were less likely to perceive that a sharp had been lost as compared to other OR team members, indicating a potential under-report bias. Improved communication between team members may increase identification, and therefore reporting, of RSS and NMS, to prevent similar incidents in the future.

UK Regulators measure never events to assess hospital safety culture and dictate reimbursement. The authors suggest that regulators focus on reducing the national never event rate through shared learning and an integrated system-wide approach, rather than concentrating on underperforming, outlier hospitals where factors such as safety culture maybe contributing to increased rates of never events.

Never events can result in serious patient harm and indicate serious underlying organizational safety problems. This study analyzed never events occurring between 2012 and 2020 in the National Health Services and categorized 51 common never events into four categories – wrong site surgery (40% of events); retained foreign objects post-procedure (28%); wrong implant/prosthesis (13%); and non-surgical/infrequent never events (19%). Awareness of these themes may support focused efforts to reduce their incidence and development of specific local safety standards. 

Never events, a significant type of adverse event, should never occur in healthcare. This study analyzed 797 surgical never events that occurred from April 2012 to February 2020 in the National Health Service (NHS) England and categorized them into three main categories: wrong-site surgery (53.58%), retained items post-procedure (44.54%), and wrong implant/prosthesis (1.88%). In total 56 common general surgery never events have been found. Being aware of the common themes may help providers to develop more effective strategies to prevent these adverse events.

Retained surgical items (RSIs) are considered ‘never events’ but they continue to occur. This quality improvement initiative found that perioperative use of radiofrequency technology was associated with fewer retained sponges and decreased risk of reoperation.