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Surg Innov. 2011 Mar;18(1):55-60. doi: 10.1177/1553350610389196. Epub 2010 Dec 27.

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

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  • 1University of Maryland, Baltimore, MD, USA.



This study sought to identify and provide preventative recommendations for potentially devastating safety violations in the operating room.


A Medline database search from 1950 to current using the terms patient safety and operating room was conducted. All topics identified were reviewed. Three patient safety violations with potential for immediate and devastating outcomes were selected for discussion using evidence-based literature.


The search identified 2851 articles, 807 of which were directly related to patient safety in the operating room. Topics addressed by these 807 included infectious complications (26%), fires (11%), communication/teamwork (6%), retained foreign objects (3%), safety checklists (1%), and wrong-site surgery (1%). Fires, gossypiboma, and wrong-site surgery were selected for discussion.


Although fire, gossypiboma, and wrong-site surgery should be "never events" in the operating room, they continue to persist as 3 common patient safety violations. This study provides the epidemiology, common etiologies, and evidence-based preventative recommendations for each.

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