Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires

The title indicates the study type and recounts the three main focal points of the inquiry. The abstract is thoroughly structured, presenting all the crucial information regarding the study in a clear and unambiguous manner, including not only the problem statement, methods, and findings but the reliability and validity measures as well. The introduction section details the events that triggered the research.

According to the authors, the surgical procedures are known to exhibit the so-called never events – critical errors of the surgeons and nursing personnel that are highly preventable and dangerous to the patient but nevertheless continue to occur. In 2004 the Universal Protocol (Stahel, 2014) was introduced, which supposedly had to eliminate or significantly decrease the space for error. However, the events persist.

The continuing occurrence of never events despite the considerable measures and resources are thus the problem statement, clearly formulated in the paper and the abstract. At the same time, little to no effort was made to systematically review the effectiveness of the protocol implementation. In fact, some sources point to the lack of measurable results of the changes in the procedure (DeVine, Chutkan, Norvell, & Dettori, 2010).

The purpose of the study given in the paper is the systematic review of the current situation. The study does not have a hypothesis, but the research question is clearly formulated: “estimating the incidence and root causes of wrong-site surgery, retained surgical items, and surgical fires and the effects of interventions aimed at preventing them.” (Hempel et al., 2015, p. 797) The paper does not specifically describe the theoretical framework, but thoroughly details the methods of data collection and analysis.

Given the exploratory nature of the study and the data source (the literature review), such approach is sufficient for the study’s credibility. The paper does not have a separate section of literature review, so the sources pertinent to the study are mostly mentioned in the introduction. However, as the literature directly relevant to the subject is scarce, the selection of reviewed sources is rather broad.

The research was conducted by reviewing the available literature describing the occurrence of never events. The study’s only exclusion criteria is the age of publications, restricted to 2004 (the date of Universal Protocol introduction) and 2014 (year of sampling). All the relevant sources were included (5399 total), which means that the sample size was limited only by the search restrictions. The literature was searched through a variety of online databases by two researchers independently.

The emerging discrepancies were resolved through discussion. This, alongside the guidance of the technical expert panel, secured the reliability and validity of the data. The description indicates no use of the supplementary sampling tools. The quantitative analysis was conducted by the surgeon experienced in systematic review methods and checked by another researcher with similar expertise. The extracted data were categorized by incidence (grouped as high, moderate, low, very uncertain, and not estimable), root causes, and intervention.

Additional effort was made to evaluate the strength of evidence by assigning Grading of Recommendations Assessment, Development and Evaluation score (Guyatt et al., 2008), guaranteeing content validity. The analysis methods are thus consistent with the study questions. The paper does not include the information regarding the analysis instruments and software. The results are concisely presented and explained in textual format and graphs.

The findings are relevant to the research question and can be grouped into three categories. First, the incidence of never events varies across the procedure types with no definitive estimates. Second, the most frequently reported and identifiable causes of the events can be collectively described as poor communication. Third, the majority of interventions to prevent the events were not conclusively defined as positive. The number of annual never events (500 wrong-site surgeries and 5000 retained surgical items) was characterized as unacceptably high when compared to other health risks, such as airline incidents (Hempel et al., 2015).

The limited success of the intervention is not direct evidence of flawed practices but is more likely to be the result of the interventions only marginally targeting never events while focusing on more common adverse effects. The finding that is arguably most relevant to nursing is the second one. Poor communication has been suggested by other researchers as the primary cause of the problem (Mehtsun, Ibrahim, Diener-West, Pronovost, & Makary, 2013).

However, the findings have several limitations. First, the research is limited by the availability and quality of data in the literature. Second, the sources rarely target the required segment (the root cause or a specific intervention) directly. Finally, the sampling was restricted to English-language literature. This, along with the data collection method, characterizes the evidence level of the study as III (Shekelle, Woolf, Eccles, & Grimshaw, 1999).

The never events in surgical procedures depend on the nursing personnel to a large degree. Nevertheless, the study in question offers only limited insight into the problem cause (poor communication) and unreliable suggestion of a possible solution (education, team training, a data–matrix–coded sponge-counting system). While an additional inquiry is needed to set the course of actions for improvement, the data on current incidence alone demands attention. Thus, the study can be used as a directive for further research and as a supplementary source of data for administrative decision-making but is otherwise of limited practical importance for individual nursing practice.


DeVine, J., Chutkan, N., Norvell, D. C., & Dettori, J. R. (2010). Avoiding wrong site surgery: a systematic review. Spine, 35(9), S28-S36.

Guyatt, G. H., Oxman, A. D., Vist, G. E., Kunz, R., Falck-Ytter, Y., Alonso-Coello, P., & Schunemann, H. J. (2008). Rating Quality of Evidence and Strength of Recommendations: GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. British Medical Journal, 336(7650), 924-926.

Hempel, S., Maggard-Gibbons, M., Nguyen, D. K., Dawes, A. J., Miake-Lye, I., Beroes, J. M.,… & Shekelle, P. G. (2015). Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. JAMA surgery, 150(8), 796-805.

Mehtsun, W. T., Ibrahim, A. M., Diener-West, M., Pronovost, P. J., & Makary, M. A. (2013). Surgical never events in the United States. Surgery, 153(4), 465-472.

Shekelle, P. G., Woolf, S. H., Eccles, M., & Grimshaw, J. (1999). Clinical guidelines: developing guidelines. British Medical Journal, 318(7183), 593-596.

Stahel, P. F. (2014). The tenth year of the “Universal Protocol”: are our patients safer today. Bone & Joint, 360(3), 7-10.

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