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From the JAMA Network
October 6, 2015

Challenges in Reducing Surgical “Never Events”

Author Affiliations
  • 1Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
  • 2Department of Surgery, Loyola University Health System, Maywood, Illinois
  • 3Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison
  • 4Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois

Copyright 2015 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA. 2015;314(13):1386-1387. doi:10.1001/jama.2015.12327

The operating room is a complex, high-risk system where adverse events remain commonplace. Certain errors, including wrong-site surgery, a retained surgical item (RSI), or an operating room fire, have been termed never events, indicating these should be 100% preventable. Despite significant attention and prevention efforts, never events still occur. It is estimated that physicians operating on bilateral structures will have a 25% lifetime risk of performing wrong-site surgery and that 1 in 8000 inpatient operations will have an RSI.1,2 These events can lead to significant physical and psychological harm to patients. The consequences can also be severe for clinicians and institutions, including the profound psychological toll on involved clinicians, as well as the financial burden of medicolegal action and negative effects on professional reputation.3