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It’s a confronting term; one that engenders a profound sense of unease. The ‘never’ conjures the unthinkable: disturbing events that just shouldn’t take place. And in the context of medical practice, it’s wholly unnerving.

Whilst it’s difficult for most of us to even begin to imagine, we are indebted to those that consider, monitor and seek to minimise what we rightly and effectively term, ‘never events.’

Though we could suggest the hard truth is that never events are impossible to make absolutely and entirely avoidable, we have every reason to strive for this, and preventative measures, reinforced by best practice, can certainly lead to never events being almost always avoided. (Patient Safety Domain, 2014, p.4)

According to the NHS England Surgical Never Events Task Force Report (Patient Safety Domain, 2014)[1], never events are most commonly reported in surgical practice. Reported surgical never events include wrong site surgery, wrong implant or prosthesis, and retained foreign objects post operation: the latter being the most common.

These events frequently hit headlines, complete with nightmarish stories of horror, reproach and condemnation. It’s understandable, and it’s important that preventable events don’t fuel sentiments that might discourage people from receiving necessary surgical treatments: “Never events can lead to very serious adverse outcomes, and they damage patients’ confidence and trust.” (Patient Safety Domain, 2014, p.4)

There were 130 reported instances of retained foreign object(s) post operation in 2012 – 2013, as reported to the Strategic Health Authorities (SHA)[2] and Strategic Executive Information System (STEIS)[3]. Foreign objects include items such as surgical swabs, needles, instruments and guidewires, and should all be subject to formal counting/ checking processes. This accounts for a significant proportion of the total of all reported never events, including non-surgical never events, and makes it a significant cause for concern.

The operating theatre presents a unique challenge: “Operating rooms are commonly intricate, high-stress environments occupied by a broad array of technological tools and inter-disciplinary staff.” (Shouhed et al, 2012) Responses to preventing never events have to consider the very real demands of the very fast, very pressured, very intense and highly challenging space of modern medical and surgical practice.

“No place epitomizes the complexity of health care delivery better than the Operating Room.” (Gibbs, 2012)

Further still, additional concern has to be conducted toward operating practices performed outside of the typical hospital based operating theatre and increasingly in day care units and day surgeries.

The challenges have been identified as largely arising from human factors: the human interaction with technology, communication and team functioning.

The user-interface or interaction between user and medical device is critical. There should be no room for misuse or misunderstanding.

Communication, in all respects, needs to be clear and precise: “Miscommunication and partial communication are widely recognised to be one of the primary sources of error in the complex surgical environment.” (Patient Safety Domain, 2014, p.27) In such an environment, practitioners are contending with the potential for misread, misheard, misunderstood and distracted or diverted communication.

Described as a ‘great live performance,’ (2014, p.28), the surgical theatre is not dissimilar to the theatre on the stage. It is a scripted performance, depending on skilled professionals executing precision timing and balanced coordination, perfected with diligent planning and rehearsal. Such an act requires accomplished team functioning: skilled, planned, experienced and coordinated interaction.

The Never Events Task Force identified errors arising from unfamiliar or differing approaches, inadequate planning and pre-op briefing, failure to effectively carry out checks before or after surgical procedures, assumptions, not double-checking, and even complacency.

A lack of standardised practice and practical protocols is recognised as problematic, increasing the risk of error. The occurrences of surgical never events demonstrate a need for systemic and standardised processes, supporting a system that reduces the possibilities for human errors.

Unsafe systems included, “Widespread toleration of variation in standard procedures such as surgical counts.” (Patient Safety Domain, 2014, p.5)

Standardisation and harmonisation requires a whole systems approach: serious patient safety incidents need to be assiduously regarded by all those involved in healthcare delivery.

In proposing a solution, The Task Force Report (2014) offered three ‘interlocking and equally vital elements:’

1) Standardising generic operating environment procedures;

2) Systematic education and training for operating theatre environments;

3) Harmonising activity to support patient safety in hospitals.

To achieve continual reduction in harm, there is a proposed need to reduce variation in practice, to promote learning from our mistakes and methods of improvement, and continue to promote organisational and professional responsibility.

The surgical swab count is a prime example of a standardised generic operating environment procedure. A procedure such as this needs to be intrinsically supported from all angles: education and training; pre and post-op briefings; product standards, attributes and handling; interaction; communication; relationships; and team functioning. Whilst count protocols are still not entirely reliable, it is essential that the aforementioned aspects are continually reviewed and improved, keenly supported by manufacturers, suppliers, healthcare providers, healthcare professionals and practitioners.

The X-Ray Detectable Cotton Gauze Swab is a combatant; yet, rightly so, advances in this method are still being reached for, with considerable research and development in the prevention of retained cotton swabs. Trialled technological aids include the ‘2D Matrix Labels’ (black and white cell pattern barcodes); devices to detect radiofrequency tagged swabs; and devices to count and detect Radio Frequency Identification (RFID) chip embedded swabs.

All development and enhancements of products and practice need to be profession-led by leaders of the profession best placed to have a deeper understanding of modern working practice and demand. Knowledge must be shared and disseminated with space for contribution, cultivation, innovation and conscience.

It is everybody’s duty to act with foresight, to recognise and regard the realities of modern practice and promote harmonising activities across the industry, remaining actively complicit in embedding best practice with an indiscriminate passion to learn and educate.

“[The ultimate aim] is to create the conditions in which front line staff can provide the quality of care they crave to give.”[4] (2014, p.7)

Written by Rebecca Porter © 2015 All rights reserved.

[1] This is also available at

[2] Strategic Health Authorities:

[3] Strategic Executive Information System:

[4] Online consultee from the NHS England Surgical Never Events Taskforce.


Gibbs VC. (2012) Thinking in three’s: changing surgical patient safety practices in the complex modern operating room. 2012 Dec 14; World J Gastroenterol. 18(46):6712-9. PubMed PMID: 23239908; PubMed Central PMCID: PMC3520159. <> [Accessed 27th November 2015].

Shouhed D, Gewertz B, Wiegmann D, Catchpole K. (2012) Integrating human factors research and surgery: a review. Arch Surg. 2012 Dec 1; 147(12):1141-6. PubMed PMID: 23248019. <> [Accessed 27th November 2015].

Suzanne Shale et al. for Patient Safety Domain. (2014) Report of the NHS England Never Events Taskforce: Standardise, Educate, Harmonise; Commissioning the Conditions for Safer Surgery. 2014 Feb 27; NHS England. <> [Accessed 27th November 2015].