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Root causes of surgical never-events: a systematic review.
Parmar, Dilen Patel, Neil Kenneth-Ogah, Catherine Yazdouni, Sadat Desai, Chaitya Raveshia, Dimit Patel, Ravi
Parmar, Dilen
Patel, Neil
Kenneth-Ogah, Catherine
Yazdouni, Sadat
Desai, Chaitya
Raveshia, Dimit
Patel, Ravi
Abstract
BACKGROUND: Never-events represent serious and preventable patient safety incidents within surgical practice, despite increasing national and international efforts to reduce them. Persistent concerns regarding wrong site surgery, retained surgical items, and incorrect implants highlight the need to understand contributory human factors and system-level weaknesses.
METHODS: A systematic search of PubMed/Medline, Google Scholar, and the Cochrane Library was conducted. Evidence published between 2014 and 2024 was screened according to predefined eligibility criteria to identify contemporary data relating to surgical never-events. Studies were assessed using standardised selection methods and relevant findings were extracted and synthesised.
RESULTS: Thirty-seven studies met inclusion criteria. Across international literature, recurring contributory factors included communication breakdowns, reduced situational awareness, fatigue, inadequate staffing, inconsistent team composition, and increasing surgical caseloads. Despite advances in safety practices, these factors continued to contribute to adverse surgical outcomes.
CONCLUSION: Never-events remain a persistent challenge in surgical care. Strengthening safety management systems, improving awareness of human factors, and prioritising non-technical skills training may help reduce the risk of these events. Ongoing evaluation of interventions and further UK-based research are required to support improvement in patient safety outcomes.
SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13037-025-00474-8.
MIDER Authors
Affiliations
The Royal National ENT and Eastman Dental Hospitals, London; Royal Shrewsbury Hospital; University of Dundee; Ninewells Hospital & Medical School, Dundee; St Mary's Hospital, London; Midland Metropolitan University Hospital, Smethwick; George Eliot Hospital, Nuneaton; The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry
Date
2026-01-08
Type
Article
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Citation
Parmar D, Patel N, Kenneth-Ogah C, Yazdouni S, Desai C, Raveshia D, Patel R. Root causes of surgical never-events: a systematic review. Patient Saf Surg. 2026 Jan 8;20(1):3. doi: 10.1186/s13037-025-00474-8.
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