This literature review explores some common factors contributing to Never Events in surgery. Despite significant patient safety efforts, serious preventable surgical events that turn into Never Events continue to exist. Various search databases were used to collect relevant contemporary data within the time parameters 2008-2019. The literature revealed numerous studies from the United States of America and worldwide, and the need for more current research from the United Kingdom on the subject. The key findings emphasise that communication failure, situational awareness, fatigue, lack of healthcare professionals and surgical caseload are common contributing factors to Never Events. The implications of these findings for practice highlight that despite multidisciplinary approaches, technologies, policies and strategies, Never Events are a common phenomenon in surgery. To minimise their occurrence, more robust and reliable safety management systems need to be in place within healthcare organisations. In depth understanding of cognitive Human Factors and non-technical skills need to be encouraged through education, training and continuous evaluation of success and failure.
Keywords: Human error / Operating room / Surgery / Never Event / Wrong site surgery / Fatigue / Stress / Harm / Skill mix / Retained / Behaviour / Patient safety / Contributing / Wrong implant / Human Factors.