---
title: Communication Failures That Cause Surgical “Never Events”
description: "This article addresses three of the events associated with surgery: retained surgical items, surgical fires, and wrong-site surgery."
image: https://files.norcal-group.com/hubfs/Screen%20Shot%202020-03-24%20at%208.43.24%20AM.png
---

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# [***CLAIMS Rx*** DIRECTORY](https://www.norcal-group.com/claimsrx)

## RISK MANAGEMENT PUBLICATION

# Communication Failures That Cause Surgical “Never Events”

April 2019

This article addresses three of the events associated with surgery: retained surgical items, surgical fires, and wrong-site surgery. All three events are rare in relation to the enormous number of surgeries performed every year in the US.

| **CASES ONE - FOUR** Unintended Retained Surgical Items **CASES FIVE - SEVEN** Surgical Fires | **CASE EIGHT ** Wrong-Site Surgery |
| --- | --- |

 

**Related Topics:** [Surgery](https://www.norcal-group.com/claimsrx/tag/surgery), [Communication](https://www.norcal-group.com/claimsrx/tag/communication), [Sentinel Event](https://www.norcal-group.com/claimsrx/tag/sentinel-event), [Surgical Fire](https://www.norcal-group.com/claimsrx/tag/surgical-fire)

surgery, surgeon,never event, surgical fire,wrong-site surgery,retained surgical item,RSI, retained sponge,sponge count,national quality forum,team briefing,surgical time out,surgical checklist,surgical safety checklist,surgical team debriefing,needle count,sentinel event,fire risk assessment,surgical fire safety policy, fire safety protocol,operating room fire,surgical site marking,correct site protocol,universal protocol

![April 2019](https://files.norcal-group.com/hubfs/Screen%20Shot%202020-03-24%20at%208.43.24%20AM.png "April 2019")

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