Surgical Never Events should never happen

Surgical procedures are intended to save lives and improve the quality of life, however omissions in essential practices (system and human error) contribute to unsafe surgical care, and cause significant harm to patients. For centuries it was believed that patients' co-morbidities and the surgeon's technical competence were the key determinants of surgical outcome; it is only within the last decade, that the relationship between failure to follow safety procedures, sub-optimal team work, poor communication and clinical outcomes has been appreciated (Vincent et al 2001). Recognition of the interdependencies for good surgical outcomes owes much to safety oriented research focusing on interpersonal behaviours and cognitive performance, the science of 'human factors', and the route cause analysis (RCA) of surgical harm.