ArticlePatient safety in surgery2026
Root causes of surgical never-events: a systematic review.
Article in Patient safety in surgery, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 2 papers.
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
2 citing papers in PubMed.
- The safety of radiofrequency surgical sponges in orthopedic surgery: a validation study in 2,251 arthroplasty procedures.Patient safety in surgery · 2026Article
- Inadvertent guidewire retention after radial artery cannulation: report of two cases and safety lessons for vascular access practice.Patient safety in surgery · 2026Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
7 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundNever-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.
methodsA 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.
resultsThirty-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.
conclusionNever-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.
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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.