Surgical safety checklists (SCC) are utilized around the world, but checklist completion at the operating room level remains inconsistent. This review summarizes facilitators and barriers to completion. Resistance or endorsement at the individual surgeon level remains a significant factor in SSC completion. Early inclusion of frontline staff in evaluation and implementation supported increased use.

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.

Patients and caregivers are important partners in promoting safe care. Findings from this cross-sectional study reinforce the importance of patients’ perceived roles in ensuring safe surgery and highlight the importance of patient engagement in mitigating surgical site 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.

The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.

Wrong-patient and wrong-site surgeries are considered never events. This commentary describes a tool developed to decrease confusion in plastic surgery. The authors envision the tool to enhance team communication and preparation, which should reduce risk of wrong-site surgery.

The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries. This commentary describes how one organization combined elements of time outs and the surgical safety checklist to augment communication and teamwork in surgical settings. Implementation of the enhanced time out involved targeted education and clarity around surgical roles and responsibilities.

Despite efforts to prevent wrong-site surgeries, they continue to occur. This commentary discusses a near miss resulting from human factors and inadequate team communication to underscore the importance of reporting and analyzing incidents to enhance individual practice and teamwork.

This review discusses wrong site surgery in otolaryngology, along with preventive strategies such as the Universal Protocol, the WHO checklist, and radiofrequency identification tags.

A quality improvement process that included forcing functions resulted in significantly improved adherence to the Universal Protocol for prevention of wrong-site procedures.

This article describes how an anatomic marking form was developed, discusses its use, and reveals the effect of this process on patient safety.

This study surveyed clinicians and discovered significant variation in their time-out and site-marking procedures in daily practice. The authors highlight the dynamic tension between national regulations and local interpretations of such policies.