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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.

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. Any team member can prevent or contribute to a surgical fire because elements of the fire triangle — air (oxygen), fuel (prepping solution, drapes, patient skin), and ignition source (electrosurgical units) — are generally controlled by different members of the surgical team. Therefore, all team members should think about how their actions might complete the fire triangle that leads to these surgical never events and should communicate with other team members about fire risk status throughout the surgery. Consider how the various surgical team members could have prevented the fire in the following case study.