Never events are catastrophic adverse events resulting in patient death or significant disability that are largely preventable. This narrative synthesis describes which events organizations most frequently identify as never events, and which are most commonly described as entirely preventable. 125 unique never events were identified, nearly 20% of which were classified as entirely preventable. The most frequent never events were wrong site or wrong patient surgery, wrong surgical procedure, and unintentionally retained objects.

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.

Root cause analysis (RCA) is a tool commonly used by organizations to analyze safety errors. This systematic review explored whether interventions implemented based on RCA recommendations were effective at preventing similar adverse events in Veterans Health Affairs (VA) settings. Of the ten retrospective studies included in the review, all reported improvements following RCA-recommended interventions implementation, but the studies used different methodologies to assess effectiveness. The authors suggest that future research emphasize quantitative patient-related outcome measures to demonstrate the impact and value of RCAs.

This study analyzed self-reported adverse events captured on a national online questionnaire to determine the association between patient-reported contributory factors and patient-reported physical, emotional or financial harm. Contributory factors identified in the analysis focused on issues with health care personnel communication, fatigue, or response (e.g., doctor was slow to arrive, nurse was slow to respond to call button). These patient-reported contributory factors increased the likelihood of reporting any type of harm.

Researchers used failure mode and effects analysis to examine intraocular lens implantation. They report uncovering many potential failure modes or safety vulnerabilities and extensive variation in how this procedure is conducted. The authors recommend standardization, changes to equipment and workflows, and quality assurance through direct observation in order to enhance safety.

This retrospective study of dental patient safety reports in the military health system demonstrated an increase in reported events, which may reflect improvements in safety culture. Wrong-site surgery was the most common adverse event, suggesting the need to enhance safety practices in dentistry.

Office-based surgery is increasingly common, despite concerns regarding its safety. This review summarizes the literature on ambulatory surgery outcomes and identified risk factors such as case complexity, patient comorbidities, and anesthesia use. Few studies examined anesthesia use in dental care.

The seminal report, To Err Is Human, famously estimated that 44,000 to 98,000 deaths per year in the United States were due to medical errors. Although certain patient harms thought to be unavoidable at the time of the report's publication in 1999 are now considered completely preventable, experts suggest that progress in the field of patient safety has been slower than initially anticipated and that areas such as ambulatory safety and diagnostic error represent emerging priorities. In this cohort study, researchers used data from 1990 through 2016 on mortality related to the adverse effects of medical treatment (AEMT) from the Global Burden of Diseases, Injuries, and Risk Factors 2016 study. For the study period, researchers attribute 123,603 deaths to AEMT. The number of such deaths increased, but the US age-standardized mortality rate for deaths due to AEMT decreased by 21% between 1990 and 2016. The authors noted similar AEMT mortality rates for men as compared to women, significantly increased AEMT mortality rates for those age 70 and older, and geographic variation with regard to age-standardized AEMT mortality rates. An Annual Perspective discussed challenges associated with measuring and responding to deaths associated with medical errors.

The Veterans Affairs Surgical Quality Improvement Program (VASQIP) and the private sector National Surgical Quality Improvement Program have transformed both safety measurement and quality in surgery. Historically, VASQIP has placed comparatively little emphasis on outpatient surgical safety. This study examined trends in hospital admission within 7 days of all outpatient surgeries performed among veterans age 65 and older in the United States. Researchers found that 16% of these procedures were associated with 7-day admission, higher than what has been observed in younger, healthier patients. Common reasons for admission included surgical, medical, or device complications and inability to secure safe aftercare at home. The authors posit that, while not every admission represents a preventable adverse event, measurement is a critical step toward improving outpatient surgical safety. A recent PSNet interview and perspective explored the evolution of surgical patient safety.