We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Review |

Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires  A Systematic Review of Surgical Never Events

Susanne Hempel, PhD1; Melinda Maggard-Gibbons, MD2,3; David K. Nguyen, MD3; Aaron J. Dawes, MD2,4; Isomi Miake-Lye, BA5; Jessica M. Beroes, BS5; Marika J. Booth, MS1; Jeremy N. V. Miles, PhD6; Roberta Shanman, MLS1; Paul G. Shekelle, MD, PhD5
[+] Author Affiliations
1Southern California Evidence-Based Practice Center, RAND Corporation, Santa Monica
2Department of Surgery, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
3Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles
4Robert Wood Johnson Clinical Scholars Program, University of California, Los Angeles
5Evidence-Based Synthesis Program (ESP) Center, West Los Angeles Veterans Affairs Medical Center, Los Angeles, California
6RAND Health, RAND Corporation, Santa Monica, California
JAMA Surg. 2015;150(8):796-805. doi:10.1001/jamasurg.2015.0301.
Text Size: A A A
Published online

Importance  Serious, preventable surgical events, termed never events, continue to occur despite considerable patient safety efforts.

Objective  To examine the incidence and root causes of and interventions to prevent wrong-site surgery, retained surgical items, and surgical fires in the era after the implementation of the Universal Protocol in 2004.

Data Sources  We searched 9 electronic databases for entries from 2004 through June 30, 2014, screened references, and consulted experts.

Study Selection  Two independent reviewers identified relevant publications in June 2014.

Data Extraction and Synthesis  One reviewer used a standardized form to extract data and a second reviewer checked the data. Strength of evidence was established by the review team. Data extraction was completed in January 2015.

Main Outcomes and Measures  Incidence of wrong-site surgery, retained surgical items, and surgical fires.

Results  We found 138 empirical studies that met our inclusion criteria. Incidence estimates for wrong-site surgery in US settings varied by data source and procedure (median estimate, 0.09 events per 10 000 surgical procedures). The median estimate for retained surgical items was 1.32 events per 10 000 procedures, but estimates varied by item and procedure. The per-procedure surgical fire incidence is unknown. A frequently reported root cause was inadequate communication. Methodologic challenges associated with investigating changes in rare events limit the conclusions of 78 intervention evaluations. Limited evidence supported the Universal Protocol (5 studies), education (4 studies), and team training (4 studies) interventions to prevent wrong-site surgery. Limited evidence exists to prevent retained surgical items by using data-matrix–coded sponge-counting systems (5 pertinent studies). Evidence for preventing surgical fires was insufficient, and intervention effects were not estimable.

Conclusions and Relevance  Current estimates for wrong-site surgery and retained surgical items are 1 event per 100 000 and 1 event per 10 000 procedures, respectively, but the precision is uncertain, and the per-procedure prevalence of surgical fires is not known. Root-cause analyses suggest the need for improved communication. Despite promising approaches and global Universal Protocol evaluations, empirical evidence for interventions is limited.

Figures in this Article


Place holder to copy figure label and caption
Incidence of Wrong-Site Surgery and Retained Surgical Items

Wrong-site surgery includes wrong site, wrong side, wrong patient, wrong implant, and wrong procedure. Error bars indicate 95% CI. Data in parentheses specify type of procedure where indicated. CVC indicates central venous catheter.

Graphic Jump Location




Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

4 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles