Surgical never events: 8 key points on incidence, root causes & potential interventions

A study published in JAMA Surgery examines the incidence, root causes of and interventions to prevent wrong-site surgery, retained surgical items and surgical fires.

Here are eight key points:

1. Researchers searched nine electronic databases for entries from 2004 through 2014, screened references and consulted experts.

2. They identified 138 empirical studies that met the inclusion criteria.

3. Median incidence estimates for wrong-site surgery in the U.S. was found to be 0.09 events per 10 000 surgical procedures.

4. The median estimate for retained surgical items was 1.32 events per 10 000 procedures, but estimates varied by item and procedure.

5. The per-procedure surgical fire incidence is unknown.

6. A frequently reported root cause was inadequate communication.

7. Limited evidence supported the Universal Protocol, education and team training interventions to prevent wrong-site surgery.

8. Evidence for preventing surgical fires was insufficient, and intervention effects were not estimable.

 

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