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.

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.

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.

Wrong-site surgery is considered a never event and can lead to serious patient harm. This analysis of closed medical malpractice claims on wrong-site surgery between 2013 and 2020 concluded that the risk of wrong-site surgery increases with spinal surgeries (e.g., spinal fusion, excision of intervertebral discs). The primary contributing factors to wrong-site surgery was failure to follow policy or protocols (such as failure to follow the Universal Protocol) and failure to review medical records.

Wrong-site, wrong-procedure, and wrong-patient errors (WSPEs) are serious adverse events. This retrospective analysis of medical liability claims data examined the incidence of WSPEs in France between 2007 and 2017. During this ten-year period, WSPEs accounted for 0.4% of all claims. Procedures on the wrong organ were most common (44%), followed by wrong side (39%), wrong person (13%) and wrong procedure (4%). The researchers found that the average number of WSPEs decreased after implementation of a surgical checklist.

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.

The perioperative setting is a high-risk environment. This continuing education model discusses safety threats and evidence-based best practices to deliver nursing care in perioperative settings and promote a culture of safety.

UK Regulators measure never events to assess hospital safety culture and dictate reimbursement. The authors suggest that regulators focus on reducing the national never event rate through shared learning and an integrated system-wide approach, rather than concentrating on underperforming, outlier hospitals where factors such as safety culture maybe contributing to increased rates of never events.

Never events, a significant type of adverse event, should never occur in healthcare. This study analyzed 797 surgical never events that occurred from April 2012 to February 2020 in the National Health Service (NHS) England and categorized them into three main categories: wrong-site surgery (53.58%), retained items post-procedure (44.54%), and wrong implant/prosthesis (1.88%). In total 56 common general surgery never events have been found. Being aware of the common themes may help providers to develop more effective strategies to prevent these adverse events.

Wrong-site surgeries can lead to serious patient harm and are considered never events by the National Quality Forum. Based on events reported to the Pennsylvania Patient Safety Reporting System between 2015 and 2019, the authors identified an average of 1.42 wrong-site surgery events per week and found that three-quarters of events resulted in temporary or permanent patient harm. The authors present several evidence-based strategies to reduce the likelihood of wrong-site surgery, including preoperative and intraoperative verification, site marking, and timeouts.  

Using a Safety-II framework, the authors used a mixed-methods approach to retrospectively analyze root cause analysis (RCA) reports of ‘never events’ occurring in the United Kingdom to characterize proposed actions, insights and recommendations to prevent future events. The analysis found that proposed actions were generally of low-to-moderate effectiveness, and that despite identifying systems challenges and weaknesses, many reports did not include proposed actions to mitigate or remove risks. The authors conclude that applying concepts from resilient healthcare can identify vulnerabilities and opportunities for strengthening the RCA system and improving the quality of RCA reports.

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.

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.

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.