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PSNet: Patient Safety Network
Journal Article
Review

Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events.

Hempel S, Maggard-Gibbons M, Nguyen DK, et al. JAMA surgery. 2015;150:796-805.

This systematic review examined surgical never events following the implementation of the Universal Protocol in 2004. Incidence estimates for retained surgical items and wrong-site surgery varied across studies, with median event rates approximately 1 per 10,000 and 1 per 100,000 procedures, respectively. There were many causes and contributing factors to these errors, but root cause analyses commonly called for better communication.