Wrong-site surgery and unintentionally retained surgical items are considered never events. This report details five wrong-site surgeries and three instances of retained surgical items at one VA medical center between 2018 and 2022. The findings suggest that timely investigation into events from 2018-2021 may have prevented three incidents in 2022. Additionally, the medical center failed to fully report the provider responsible for three of the wrong-site surgeries.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery. Since 2003, Minnesota hospitals have been required to report such incidents. The 2022 report summarizes information about 572 adverse events that were reported, representing a significant increase in the year covered. Earlier reports prior to the last two years reflect a fairly consistent count of adverse events. The rise documented here is likely due to demands on staffing and care processes associated with COVID-19 and general increases in patient complexity and subsequent length of stay. Pressure ulcers and fall-related injuries were the most common incidents recorded. Reports from previous years are available.

This annual report summarizes never events in Maryland hospitals over the previous year. During fiscal year 2022, reported events increased due to the COVID pandemic, workforce shortages and other system demands. Events contributing to patient deaths and severe harm from preventable medical errors during the time period doubled. The authors recommend several corrective actions to enhance improvement work, including board and executive leadership engagement in safety work and application of high-reliability concepts to enhance safety culture.

Otolaryngology-head and neck surgery is vulnerable to wrong site errors and other challenges present in surgical care. This series of articles highlights key areas of importance for the specialty as they work to enhance patient safety. The latest 2023 installment covers measurement.

Retained surgical items (RSIs) are considered “never events” but continue to be a source of patient harm. This article discusses the various factors that increase risk of RSIs and strategies to prevent them, such as a consistent counting process and fostering a culture of safety that encourages speaking up and a non-punitive response to errors.

Racial and ethnic inequalities are emerging as a primary contributor to harmful maternal care. This guidance examines obstacles to safe care for mothers of color and shares recommendations to reduce disparities such as team-based care and implicit bias training.