Perceptions of surgical never events among interdisciplinary clinicians: Implications of a qualitative study for practice: Mental Models and Never Events

Background: Never Events are serious, preventable, and clearly identifiable medical errors with the potential for causing patients significant morbidity and mortality. Despite extensive efforts to eliminate them, Never Events persist. Aim: To assess whether interdisciplinary clinicians (nurses, surgeons, and anaesthesiologists) and risk managers have different mental models about three aspects of the definition of surgical Never Events: incidence, severity, and preventability. Methods: Semi-structured interviews were conducted with 25 operating room clinicians and hospital risk managers in Israel from September to December 2019. Verbatim transcripts were analysed using six-phase inductive thematic analysis. Findings: Mental models of Never Events varied by profession. Surgeons described them as rare and nurses saw them as common. While agreeing on their severity, mental models about preventability were mixed, with surgeons and nurses thinking that training and/or safety standards could prevent them, and anaesthesiologists and risk managers considering them to be unpreventable. Discussion: The common definition of Surgical Never Events characterises them as severe and preventable events. Different mental models characterise interdisciplinary views about the definition. These differences challenge the utility of a single international consensus definition of Never Events. Conclusion: Given differences in mental models among clinicians and risk managers, approaches to eliminating Never Events may benefit from identifying and addressing these differences in order to improve teamwork and implementation of safety protocols.