Observational studySurgery2015
Surgical never events and contributing human factors.
Observational study in Surgery, 2015. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 34 papers, 2 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
34 citing papers in PubMed, 2 syntheses or guidelines pooled it, 124 citations in OpenAlex.
- Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis.BMJ open quality · 2023Pooled it
- Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review.World journal of surgery · 2019Pooled it
- Product and Equipment Coding in National Practitioner Data Bank Malpractice Payment Reports, 2019-2025.Cureus · 2026Article
- Root causes of surgical never-events: a systematic review.Patient safety in surgery · 2026Article
- Measuring Workflow Interruptions in Endoscopy: Development and Interrater Reliability of a Structured Observation Tool.Endoscopy international open · 2026Article
- Deep learning-based object detection of restorative dental instruments with potential implications for workflow automation and infection control in dental supply units.Scientific reports · 2025Article
- Observational
- Safety Culture and Human Factors in Foreign Object Management in Surgery.Healthcare (Basel, Switzerland) · 2025Article
- Wrong-site, wrong-procedure, and retained foreign object events in out-of-hospital settings: analysis of closed medico-legal complaints in Canada (2012-2021).Patient safety in surgery · 2025Article
- Review
- Interdisciplinary Strategies to Reduce Surgical Infectious Risk in the Operating Theater: Protocol for Scoping Review.JMIR research protocols · 2025Article
- Speech communication interference in the robotic operating room.Journal of robotic surgery · 2024Article
- Nurse understaffing associated with adverse outcomes for surgical admissions.The British journal of surgery · 2024Article
- Artificial intelligence model for automated surgical instrument detection and counting: an experimental proof-of-concept study.Patient safety in surgery · 2024Article
- Fallibility, performance, patient safety and teamwork: embedding human factors in surgery.Annals of the Royal College of Surgeons of England · 2024Article
- Exploring Intraoperative Cognitive Biases in Cardiac Surgery Teams.Applied Human Factors and Ergonomics Conference · 2024Article
- Article
- The Incidence of Retained Objects in Intraoperative X-rays for Missing Counts in Plastic Surgery: We Should Do Better.Plastic and reconstructive surgery. Global open · 2023Article
- Factors contributing to preventing operating room "never events": a machine learning analysis.Patient safety in surgery · 2023Article
- Application of "Human Factor Analysis and Classification System" (HFACS) Model to the Prevention of Medical Errors and Adverse Events: A Systematic Review.International journal of preventive medicine · 2023Review
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
10 authors at 2 institutions in 1 country.
Funding
Abstract
introductionWe report the first prospective analysis of human factors elements contributing to invasive procedural never events by using a validated Human Factors Analysis and Classification System (HFACS).
methodsFrom August 2009 to August 2014, operative and invasive procedural "Never Events" (retained foreign object, wrong site/side procedure, wrong implant, wrong procedure) underwent systematic causation analysis promptly after the event. Contributing human factors were categorized using the 4 levels of error causation described by Reason and 161 HFACS subcategories (nano-codes).
resultsDuring the study, approximately 1.5 million procedures were performed, during which 69 never events were identified. A total of 628 contributing human factors nano-codes were identified. Action-based errors (n = 260) and preconditions to actions (n = 296) accounted for the majority of the nano-codes across all 4 types of events, with individual cognitive factors contributing one half of the nano-codes. The most common action nano-codes were confirmation bias (n = 36) and failed to understand (n = 36). The most common precondition nano-codes were channeled attention on a single issue (n = 33) and inadequate communication (n = 30).
conclusionTargeting quality and interventions in system improvement addressing cognitive factors and team resource management as well as perceptual biases may decrease errors and further improve patient safety. These results delineate targets to further decrease never events from our health care system.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.