Operating room list errors are often cited as leading to wrong-side, wrong-site or wrong-procedure errors. This retrospective study analyzed two years of data from the United Kingdom and found that while no wrong-side, wrong-site or wrong-procedure surgeries were performed during the period, 0.29% of cases (86 cases) included a list error. Wrong-side list errors accounted for the majority of all list errors (72%). Tracking and reducing operating room list errors may help to prevent wrong-side, -site, or -procedure errors.

Reporting and avoidance of “never events,” such as a wrong tooth extraction, is important for providing consistently safe dental care. This article describes changes made in safety procedures, including introducing surgical safety briefings or huddles in an outpatient oral surgery unit of the United Kingdom’s National Health Service, that eliminated never events for more than two years.

Deviations from the previously agreed upon perioperative care plan were associated with an increased risk of adverse events during surgery. Unplanned changes in surgical procedures have been previously associated with higher risk for retained surgical instruments.

Parents of hospitalized children feel personally responsible for their children's safety, and efforts are being made to engage parents in safety efforts. This retrospective review of incident reports found more than 100 cases in a 5-year period in which parents were directly involved in adverse events in a pediatric intensive care unit. These included cases where parents detected an adverse event as well as cases where the parents caused the adverse event (for example, by accidentally disconnecting equipment). The authors advocate for development of a safety culture that encourages parents to report concerns, a goal that is a major focus of the Josie King Foundation.

This study combined implementation of verification protocols with periodic audits and feedback to increase compliance with patient identification in the prevention of wrong-patient and wrong-site surgery. While the process did improve, the authors advocate for technological solutions to address the limitations of purely manual systems. A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site surgery.

The authors interviewed surgeons involved in wrong-site incidents and found that the errors of omission were primarily due to distractions in the operating environment.