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-site procedures are considered never events, yet they continue to occur. This review describes the incidence, impacts, and contributing factors of wrong-site nerve blocks. The authors recommend verifying the procedure and patient with multiple sources of information, using visible site markings, and employing time outs immediately prior to anesthetic use. A WebM&M commentary discussed an incident involving a wrong-site nerve block.

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.

This commentary describes a case of wrong-site surgery, an erroneous breast biopsy, and the resulting disclosure of the error and investigation. Root cause analysis uncovered multiple process vulnerabilities. The authors suggest that errors provide opportunities to design system solutions to prevent errors.

Wrong-site surgery represents a never event. In the United States, The Joint Commission requires marking of the surgical site prior to surgery as part of the Universal Protocol. Researchers conducted a survey study of 120 surgeons in the United Kingdom and found significant variation in adherence to the national mandate for preoperative surgical site-marking.

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.

Checklists are a popular strategy to improve teamwork and prevent errors. Reviewing the evidence on the use of checklists in surgery, this commentary highlights how the tool and associated time out have reduced some adverse events and helped to manage hierarchy in the operating room.

This systematic review examined surgical never events following the implementation of the Universal Protocol in 2004. Incidence estimates for retained surgical items and wrong-site surgery varied across studies, with median event rates approximately 1 per 10,000 and 1 per 100,000 procedures, respectively. There were many causes and contributing factors to these errors, but root cause analyses commonly called for better communication.

Despite large-scale efforts to prevent wrong-site surgeries, they continue to occur. This concept analysis found limited evidence regarding the role of nurses in wrong-site surgery and recommends that future research focus on theoretical frameworks around how preoperative nurses can help avert these never events.

Wrong-side procedures still occur at alarming rates, particularly outside of the operating room. This study exposed medical students to various types of distractions and measured their ability to distinguish a person's left from right side from different perspectives. Cognitive distractions had a bigger negative impact than ambient ward noise on the students' performance.

Wrong-surgery errors continue to occur despite their status as never events. This study found that wrong-site block occurred at a rate of about 1 per 10,000 nerve blocks, and these persisted even after implementation of time out procedures. The authors highlight the need to develop interventions to prevent these events.

This systematic review investigated root causes of wrong-site surgery and identified three vulnerabilities: transcription errors prior to surgery, intraoperative verification failures, and omitting steps in the verification process. The Universal Protocol does not mitigate these vulnerabilities, suggesting that further interventions are required to prevent wrong-site surgeries. A recent AHRQ WebM&M commentary provides an overview of wrong-site surgery and best practices to prevent it.

Organizations including The Joint Commission, the World Health Organization, and the Centers for Medicare and Medicaid Services have focused on improving surgical safety. Using Reason's Swiss cheese model, this review analyzes the evidence for surgical checklist implementation to determine its usefulness in preventing wrong-site surgery and recommends tactics to address weaknesses.