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Wrong-site surgery incidents are usually due to multiple processes that combine to cause the event, as opposed to one specific error.

Never event was coined in 2001 to describe medical errors that should never happen. The National Quality Forum (NQF) now lists 29 types of never events¹ (also referred to as “serious reportable events” by NQF and “sentinel events” by The Joint Commission). The linked case studies address examples of surgical adverse incidents that would be considered never events: retained surgical items, surgical fires, and wrong-site surgery.

Surgical fires occur in a wide variety of medical settings, from solo practices to large hospitals. Surgical fire prevention depends mostly on fire risk awareness and communication among the members of the surgical team.

Surgical fires occur in a wide variety of medical settings, from solo practices to large hospitals. Surgical fire prevention depends mostly on fire risk awareness and communication among the members of the surgical team.

An unintended retained surgical item (RSI) is an item unintentionally left inside a patient¹ (in this case a cautery tip). Among surgical never events, RSI is the most frequently reported to the Joint Commission.² According to the Joint Commission, the most common causes of RSIs include the absence of policies and procedures, failure to comply with existing policies and procedures, and inadequate or incomplete staff education.³ In this case, the surgical staff’s unfamiliarity with new electrocautery units led them to disregarded the policy for counting tips and inspecting the units following use leading to the retained surgical item.