Poor communication remains at the heart of most surgical “never events” (i.e., preventable events), say the authors of a systematic review that estimates around 500 wrong-site surgeries and 5,000 retained surgical items incidents still happen each year in the United States.

The review of 138 empirical studies of wrong-site surgery, retained surgical items, and surgical fires, published between 2004 and 2014, found wrong-site surgery occurred roughly once per 100,000 surgical procedures, and retained surgical items incidents at a rate of 1.32 events per 10,000 procedures, with unknown data on the per-procedure incidence of surgical fire, according to data published online June 10 in JAMA Surgery.

“A frequently reported cause of wrong-site surgery across 28 identified analyses was communication problems, including miscommunications among staff, missing information that should have been available to the operating room staff, surgical team members not speaking up when they noticed that a procedure targeted the wrong side, and a surgeon ignoring surgical team members who questioned laterality,” wrote Susanne Hempel, PhD, of the Southern California Evidence-Based Practice Center, Santa Monica, and her coauthors.

They found that very few evaluations of interventions designed specifically to reduce the incidence of never events were conclusive, although they pointed out that given the rarity of these events, it was methodologically challenging to assess the effectiveness of these interventions (JAMA Surg. 2015 June 10 [doi:10.1001/jamasurg.2015.0301]).

The Department of Veterans Affairs supported the study. There were no conflicts of interest declared.