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Perceptions of surgical never events among interdisciplinary clinicians: Implications of a qualitative study for practice

Open AccessPublished:October 05, 2022DOI:https://doi.org/10.1016/j.colegn.2022.09.012

      Abstract

      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.

      Keywords

      Summary of relevance

      Problem

      Never Events persist despite extensive efforts to eliminate them.

      What is already known

      Among strategies for eliminating Never Events are efforts to promote patient safety cultures characterised by effective interprofessional teamwork. The literature demonstrates that high functioning healthcare teams have shared knowledge structures – or mental models – regarding patient safety. Nevertheless, less is known about the underlying characteristics of these mental models.

      What this paper adds

      This study explores mental models of 25 clinicians and risk managers with regard to Surgical Never Events and finds patterns of variability concerning their seriousness, preventability, and incidence – with implications for training and patient safety.

      1. Introduction

      Never Events were first defined by the National Quality Forum in 2001 as an outcome of voluntary stakeholder consensus process (
      • Kizer K.W.
      • Stegun B.S.
      Serious reportable adverse events in health care. advances in patient safety: from research to implementation.
      ). They include serious, preventable adverse events with potentially serious consequences for patient morbidity and mortality. Although the definition has varied somewhat and has evolved over time in different countries, these elements are typically present in all definitions (
      • Robert M.C.
      • Choi C.J.
      • Shapiro F.E.
      • Urman R.D.
      • Melki S.
      Avoidance of serious medical errors in refractive surgery using a custom preoperative checklist.
      ). Such events include, for example, severe bedsores or major medication errors. Surgical Never Events, a subset of Never Events, include performing surgery on the wrong site or the wrong patient, performing the wrong surgical procedure, and unintended retention of a foreign object in a patient's body after surgery, intraoperative, or immediately postoperative death in otherwise healthy patients (
      National Quality Forum
      Serious reportable events in healthcare—2011 update: a consensus report.
      ). In Israel, the incidence of retained foreign objects during surgery is 3.2 in every 100,000 surgeries (
      OECD
      Foreign body left in during procedure, 2017 (or nearest year). In: Quality and outcomes of care.
      ). The incidence of wrong site surgeries is unclear but is generally estimated as one in every 100,000 surgeries. These events can lead to physical and emotional suffering and financial burden to patients and can also impact surgeons and the institution who blame themselves for the error (
      • Kumar J.
      • Raina R.
      Never events in surgery”: mere error or an avoidable disaster.
      ).
      Multiple efforts have been undertaken to prevent Surgical Never Events worldwide, including a surgical safety checklist developed by the World Health Organization (
      • Kumar J.
      • Raina R.
      Never events in surgery”: mere error or an avoidable disaster.
      ;
      World Health Organization
      WHO guidelines for safe surgery 2009: Safe surgery saves lives.
      ). Other efforts include quality improvement training, root cause analysis, and team huddles. Among organisational strategies for eliminating never events are efforts to promote a patient safety culture (
      • Moppett I.K.
      • Moppett S.H.
      Surgical caseload and the risk of surgical never events in England.
      ) by listening and relating to employee voices (
      • Martin G.P.
      • Chew S.
      • Dixon-Woods M.
      Uncovering, creating or constructing problems? Enacting a new role to support staff who raise concerns about quality and safety in the English National Health Service.
      ), by encouraging effective interprofessional teamwork, intraoperative communication, and by improving ability to manage disruptions (
      • Mathew R.
      • Markey K.
      • Murphy J.
      • Brien B.O.
      Integrative literature review examining factors affecting patient safety with robotic-assisted and laparoscopic surgeries.
      ). An attribute of the high functioning teams required to implement these approaches is shared mental models in relation to safety (Aveling, et al., 2017). Mental models are individually held knowledge structures around the dimensions of content, similarity, accuracy, and dynamics. Shared mental models can help team members to function collaboratively (
      • McComb S.
      • Simpson V.
      The concept of shared mental models in healthcare collaboration.
      ).
      Two studies have analysed interprofessional mental models in the Operating Room (
      • Brown E.H.
      • Harder K.A.
      • Apostolidou L.
      • Wahr J.A
      • Shook D.A.
      • Farivar R.S.
      • et al.
      Identifying variability in mental models within and between disciplines caring for the cardiac surgical patient.
      ,
      • Aveling E.
      • Stone J.
      • Sundt T.
      • Wright C.
      • Gino F.
      • Singer S.
      Factors influencing team behaviors in surgery: a qualitative study to inform teamwork interventions.
      ), but neither directly probed clinician views on the fundamental definition of Never Events.
      • Brown E.H.
      • Harder K.A.
      • Apostolidou L.
      • Wahr J.A
      • Shook D.A.
      • Farivar R.S.
      • et al.
      Identifying variability in mental models within and between disciplines caring for the cardiac surgical patient.
      found that variability in mental models hampered communication among members of a cardiac perioperative team at critical care transition points.
      • Schiff L.
      • Miele K.
      • McCollum M.
      • Li Q.
      • Connolly A.M.
      Teaching and sustaining a shared mental model for intraoperative communication and teamwork.
      determined that uptake of a training tool for improving teamwork was hampered by variable mental models among members of a surgical gynaecology team. While a study by
      • Göras C.
      • Nilsson U.
      • Ekstedt M.
      • Unbeck M.
      • Ehrenberg A.
      Managing complexity in the operating room: a group interview study.
      notes that mental models are created by shared planning to improve safety, it did not explore the underlying characteristics of varying mental models. Most relevant to the present study,
      • McComb S.A.
      • Lemaster M.
      • Henneman E.A.
      • Hinchey K.T.
      An evaluation of shared mental models and mutual trust on general medical units: implications for collaboration, teamwork, and patient safety.
      found that physicians and nurses have significantly different mental models. These are reflected in their divergent views on who is responsible for a number of activities closely related to patient safety, including patient advocacy, identifying errors and near misses, and medication reconciliation. These differences, can affect clinicians' actions during surgical procedures and are related to their knowledge and practice (
      • Flug J.A.
      • Ponce L.M.
      • Osborn H.H.
      • Jokerst C.E.
      Never events in radiology and strategies to reduce preventable serious adverse events.
      ). Despite the potential significance of different mental models for patient safety, little is known about the mental models of clinicians with regard to the concept of Never Events. This study aims to assess whether interdisciplinary clinicians and risk managers have different mental models about the definition of surgical Never Events, including their seriousness, preventability, and incidence. We also consider possible implications of varying mental models for patient safety training and protocols.

      2. Methods

      2.1 Study design

      This qualitative study relied on data from semi-structured, in-person interviews with operating room clinicians and hospital risk managers, based on what was anticipated to be sufficient to reach data saturation. The semi-structured interviews were performed according to a literature-based guide that was developed by the authors and validated by surgery and risk management experts. The guide included open-ended questions specifically intended to explore the participants’ mental model with regard to aspects of the definition of perioperative Surgical Never Events (see Table 1).
      Table 1Interview guide.
      Discussion topicsExamples of questions
      Attitude toward “Never Events” in operating rooms in IsraelHow would you define “Never Events” in operating rooms?
      PROBE: Are there different types of “Never Events” in operating rooms?
      PROBE: Preventable vs not preventable
      Personal experience with “Never Events” in the operating roomHave you been exposed to a “Never Event” in the operating room? If yes, can you please tell me what happened?
      PROBE: In your opinion, what were the main causes of the “Never Event” in this case?
      PROBE: Do you think the “Never Event” in this case was preventable?
      PROBE: Do you have any suggestions for how to avoid a case like that in the future?
      To evaluate the guide, two pilot interviews were conducted, resulting in one question being omitted. The data from the pilot study were added to the final analysis. Field notes were taken during and immediately after each interview in which the interviewers described the participants’ familiarity with components of the Never Events definition and recorded any nonverbal reactions, such as anger or discomfort, during the interview. Conversations were recorded and verbatim transcripts of each interview were produced.

      2.2 Participants and sample

      The interviewees were selected using a purposive recruitment (
      • Cheung W.J.
      • Patey A.M.
      • Frank J.R.
      • Mackay M.
      • Boet S.
      Barriers and enablers to direct observation of trainees’ clinical performance: a qualitative study using the theoretical domains framework, academic medicine.
      ) from different general hospitals. Participants were included who had an administrative role, frontline experience, and systemic views of surgical Never Events. Exclusion criteria eliminated participants who were either trainees or staff members without an administrative role. In-person interviews were conducted at participants’ settings from September to December 2019 by one of the study's authors (DA) and were recorded and transcribed verbatim. The interviews lasted 20 min each on average.
      Overall, 25 participants participated in the study. All were employed at nine Israeli hospitals or at the Israeli Ministry of Health (see Table 2). Although all subjects held administrative positions, 19 of the 25 had also worked (currently or previously) in operating rooms. The risk managers from hospitals and the Ministry of Health had a role in risk assessment in the operating room and policy development accordingly. The hospitals included four large urban trauma centres (>800 beds); three medium-sized (400–800 beds) rural centres, one of which was also a trauma centre; and two small centres (<400 beds), one rural and the one urban, providing only surgical care.
      Table 2Characteristics of study participants.
      CharacteristicRespondents number (%) (Total = 25)
      Age (years)
      35–443 (12)
      45–5410 (40)
      55–6410 (40)
      65–752 (8)
      Sex
      Male10 (40)
      Female15 (60)
      Profession
      Operating room clinician6 (24)
      Anaesthesiologist3 (12)
      Surgeon9 (36)
      Nurse3 (12)
      Risk manager (physician) Risk manager (nurse)4 (16)
      Administrative role
      Yes25 (100)
      No0
      Experience in profession (years)
      10–195 (20)
      20–297 (28)
      30–3910 (40)
      40–503 (12)
      Years in current position
      0–49 (36)
      5–99 (36)
      10–142 (8)
      15–191 (4)
      20–254 (16)

      2.3 Data analysis

      The researchers manually entered information from the transcripts into Microsoft Excel, (version 16.0), using the six-phase inductive thematic analysis approach as described by
      • Braun V.
      • Clarke V.
      Using thematic analysis in psychology.
      : (i) familiarisation with the data, (ii) generating initial codes, (iii) searching for themes, (iv) reviewing themes, (v) defining and naming themes, and (vi) producing the report. Two of the study's authors read and reread the entire data set and systematically, and independently, coded the transcripts. Codes were then grouped into emergent themes after iterative reading and discussion with two different authors. The entire team met several times throughout the analysis process to discuss disagreements and refine and label the themes descriptively and interpretatively (
      • Lindgren B.
      • Lundman B.
      • Graneheim U.H.
      Abstraction and interpretation during the qualitative content analysis process.
      .
      We followed
      • Tracy S.J.
      Qualitative quality: eight “big-tent” criteria for excellent qualitative research.
      criteria for qualitative best practices. Transparency was maintained throughout the process of sorting, choosing and organising data. The rigor of data analysis was achieved through the development of a rational framework to transform and organise raw data into the research report. The first and second authors analysed the data and shared it with the research team to ensure triangulation. Finally, the information was shared continuously with team members during the analysis, with their various professional expertise strengthening the credibility of the analysis.

      3. Findings

      The analysis revealed themes clustering around two main themes: professionals’ perceptions of the formal definition of Never Events; and perceptions around various characteristics of the definition of Never Events.

      3.1 Professionals’ perceptions of the definition of Never Events

      The participants shared their perceptions of the common definition of Never Events and its concept. Risk managers endorsed the formal definition, whereas most of the operating room clinicians suggested modifying the definition. These clinicians suggested a broader definition to include any event that puts the success of the surgery at risk, but this was based on their own professional role in the surgery. For example, nurses related to their role of being accountable for the patient's safety: “If I want the patient not to fall, I will stand next to him and make sure the stretcher is braked while he is being transferred.” One surgeon viewed inappropriate preparedness for the surgery as a Never Event: “For me, a ‘never event’ is nonsharpened scissors.” and a majority of the anaesthesiologists defined a Never Event as a surgery with an unexpected occurrence of events, including “unexpected death during surgery”, “wrong blood transfusion”, “wrong organ anesthesia”, and “wrong medication administration”.
      Risk managers related to the formal regulatory definition of Never Events with a modification to patient's harm—for example, “There is a definition [from] the Ministry of Health”, and “In the Operating Room, there are three types of ‘never events’: error in patient identification, wrong site surgery, [and] surgery to the wrong patient” and suggested adding “Loss of tissue should be included in the definition….It mustn't happen [for] somebody [to go] through a surgery in order to know if he has cancer or not”, and “The issue of patient identification should be a critical aspect in ‘never events’”.

      3.2 Perceptions of various characteristics of the definition

      3.2.1 Incidence and measurability of Never Events

      Perceptions of incidence of Never Events varied among nurses and physicians. Nurses perceived these events as common: “In my opinion, they are very common, especially with regard to their severity” There are patients [who] fall, burns during surgery, and problems with surgical counts, these are common events”. Surgeons perceived the events as rare and related to the implementation of safety standards in the Operating Room: “The events are rare because everybody implemented correct signing, [which] was the major issue in these events…Lack of following work protocols is very simple; it is caused by distraction, working at night, and burnout”, and “[A Never Event is] very rare; it might happen [once] every few years”.
      Anaesthesiologists thought that the events were rare but unpredictable and thus hard to measure due to the dynamic work environment in the Operating Room: “An adverse event that surprisingly occurs within our usual routine and is exceptional and unusual”. Another described an unnoticed oesophageal intubation that caused the patient severe harm. A case of unpredictable wrong use of equipment, that we did not [take] notice of, during bronchoscopy that caused the patient harm”.
      Risk managers thought that some characteristics of the surgery might increase the incidence of Never Events. These characteristics challenge the measurability of an incident since they consider some errors to be unpredictable. One noted that obstetrics and gynaecology “is [a] high-risk specialty since many surgeries are urgent…also trauma surgeries because the team skips the safety standards due to the urgency”. Another pointed out that, “In general, when the surgery is more complicated, the chance for [a] ‘never event’ is higher because when one needs to give attention to so many details, one starts creating shortcuts and doing things automatically”.

      3.2.2 Severity and preventability characterising the definition of Never Events

      All participants described their perceptions of two characteristics of the definition of Never Events: severity and preventability (Table 3). There was a consensus among nurses and physicians that severity – or, the potential for serious patient harm – is an essential element of the definition and is related to the complexity of the surgery and the work environment in the Operating Room. An anaesthesiologist further described the importance of the anaesthesiologist's role in quickly decreasing the severity of an emerging event with a rapid response. Moreover, a surgeon stated that a surgical Never Event indicates a serious safety hazard in the operating room that resulted in severe patient harm. Even though there was a consensus regarding the severe outcome of Never Events, a risk manager thought that these events can be graded by their potential severity.
      Table 3Perceptions of clinicians and risk managers regarding aspects of the formal “Never Event” definition.
      Severity“Never Events” are severe events that cause patient harm
      • -
        “In my opinion, [a] ‘never event’ is an event that included [a] patient's harm, occurred during routine surgery, or [was a] procedure that must not happen.”– a nurse
      • -
        “Based on the fact that most ‘never events’ occur or may occur in the OR, it is an important issue that should be related to as severe events.” – a risk manager
      • -
        “A safety event with severe patient harm or even death in a way that was preventable…It is not related to the elements that I operated [on in] the patient, and he was severely sick and then he passed and a harm occur[red]. It is an event of [a] retained foreign object such as pad/sponge, [or] major harm such as damage to a vital organ.” – a surgeon
      The severity of events can be graded and depends on the rapidity of response
      • -
        “I would define the type of event such [as a] burn occurring during surgery at the same severity level as retention of [a] foreign object during surgery and definitely not as wrong [as a] blood transfusion that caused [a] patient's death” – a risk manager
      • -
        “Since the patient care we provide is one on one, it is easier for us to decrease the severity of events. If we give wrong medication, we can immediately recognise the error and provide care in five second[s] [to] decrease the potential severity.” – an anesthesiologist
      PreventabilitySurgical “Never Events” are preventable by increased awareness, training, and following work protocols
      • -
        “Since all ‘Never Events’ have a risk for patient harm, we should prevent their occurrence in the OR.” – a nurse
      • -
        “We count items during the surgery exactly by the rules; it is important to prevent errors.” – a nurse
      • -
        “I think that they are all preventable. Everybody has awareness for preventing them and proper training for such awareness.” – a surgeon
      • -
        “The types of surgeries with their special characteristics, like long surgeries with addition of absorbing materials/gauzes; in such surgeries, the surgical count should be done very carefully.” – a risk manager
      Some events cannot be prevented owing to human errors and force majeure
      • -
        “There is certain rate of human errors; we are unable to reach zero with these errors…with attention and proper standards, we can prevent all events except events that are related to [an] unknown factor/condition of the patient that you are not aware [of].” – a nurse
      • -
        “Most ‘Never Events’ are preventable, but [a] large amount of them are not.” – an anesthesiologist
      • -
        “The patient was restrained to the surgical bed and somehow the bed broke and he fell.” – an anesthesiologist
      The characteristics of the surgery affect the ability to prevent “Never Events”
      • -
        “Performance of surgery in an airway [or] close to an airway created risk for catching fire in that area” – a nurse
      • -
        “You use oxygen, you use electricity, and together it can lead to a surgical burn.” – a surgeon
      Preventability refers to the possibility of avoiding Never Events through increased awareness, training, and work protocols. Nurses thought that adhering to safety standards and using tools such as training, awareness, and work protocols can prevent most Never Events. However, they thought that some human errors resulting in Never Events cannot be prevented by safety standards alone.
      Two surgeons thought that proper training could help prevent Never Events, whereas other participants said that some events are not preventable due to the inherent risks in some procedures (i.e., the combination of electricity and oxygen can lead to burns). Anaesthesiologists thought that not all Never Events are preventable and described situations of “force majeure”, such as a patient's fall or a surgical burn, which can occur even if standards are upheld.

      4. Discussion

      Since the first definition of 'Never Events' was advanced by the National Quality Forum in 2001 (
      • Kizer K.W.
      Patient safety: a call to action: a consensus statement from the national quality forum.
      ), other health care organisations have adopted what has become a consensus definition (;
      World Health Organization
      WHO guidelines for safe surgery 2009: Safe surgery saves lives.
      ). This study aimed to assess any variability in mental models among interdisciplinary clinicians and risk managers with regard to key aspects of the definition, including the incidence, seriousness, and preventability of surgical Never Events. The findings suggest that mental models about surgical Never Events varied among professions, particularly with regard to their incidence and preventability, a result with implications for efforts to eliminate them.
      Focusing on the three key dimensions of Never Events, in our study, surgeons consider the incidence of surgical Never Events to be rare, while nurses say they are common. Interviewees agreed that Never Events are severe, as defined by many international organisations (
      • Robert M.C.
      • Choi C.J.
      • Shapiro F.E.
      • Urman R.D.
      • Melki S.
      Avoidance of serious medical errors in refractive surgery using a custom preoperative checklist.
      ), but had different opinions about whether all are actually preventable. A systemic review of 47 studies by
      • Jung J.J.
      • Elfassy J.
      • Jüni P.
      • Grantcharov T.
      Adverse events in the operating room: definitions, prevalence, and characteristics. a systematic review.
      revealed a variation in the incidence of intraoperative adverse events that is related to their mode of detection. Twenty of the 47 studies reviewed referred to the events based on their severity and level of patient harm, and eight defined the events as unanticipated and preventable. Moreover, the clinicians modified the definition of a Never Event to conform to their specific training and roles in a surgical procedure. This meant that surgeons focused on performing the surgery, anaesthesiologists focused on stabilising patients, and nurses on coordination and patient assistance. In our study, risk managers focused more on potential risks for patient harm, congruent with their role as promoters of patient safety and error preventers (
      • Card A.J.
      The varied and expanding role of risk management practice.
      ).
      The variations we found regarding incidence might also be explained by a dynamic work environment that affects the occurrence of Never Events (
      • Göras C.
      • Nilsson U.
      • Ekstedt M.
      • Unbeck M.
      • Ehrenberg A.
      Managing complexity in the operating room: a group interview study.
      ). Thus, nurses might perceive more of the risks in the operating room that can lead to occurrence of Never Events in their routine work (
      • Haugen A.S.
      • Murugesh S.
      • Haaverstad R.
      • Eide G.E.
      • Softeland E.
      A survey of surgical team members’ perceptions of near misses and attitudes towards time out protocols.
      ). Regardless of their origin, our findings around mental models have implications for efforts to reduce Never Events.

      4.1 Implications for practice

      Agreement on the basic attributes of Never Events, particularly among the staff who are central to providing surgical care, would seem to be required for effective – and safe – interprofessional teamwork. All components of communication, trust, respect, mutual acquaintanceship, and more are related to the existence of shared mental models around the required tasks and the environment in which collaboration happens (
      • Karam M.
      • Brault I.
      • Van Durme T.
      • Macq Jean
      Comparing interprofessional and interorganizational collaboration in healthcare: a systematic review of the qualitative research.
      ). Studies show that teamwork is essential for the prevention of Never Events (
      • Stahel P.F.
      • Cobianchi L.
      • Dal Mas F.
      • Paterson-Brown S.
      • Sakakushev B.E.
      • Nguyen C.
      • et al.
      The role of teamwork and non-technical skills for improving emergency surgical outcomes: an international perspective.
      ), from the safe conduct of the surgery itself to the implementation of safety tools, like checklists (
      • Moppett I.K.
      • Moppett S.H.
      Surgical caseload and the risk of surgical never events in England.
      ). Effective teams have a shared understanding of the complexity of a clinical situation, make appropriate decisions, and act efficiently (
      • Mitchell R.J.
      • Parker V.
      • Giles M.
      When do interprofessional teams succeed? Investigating the moderating roles of team and professional identity in interprofessional effectiveness.
      ).
      Moreover, tracking the incidence of Never Events and the impact of improvement efforts relies on accurate measurement (
      • Cohen A.J.
      • Lui H.
      • Zheng M.
      • Cheema B.
      • Patino G.
      • Kohn M.A.
      • et al.
      Rates of serious surgical errors in California and plans to prevent recurrence.
      ), which in turn depends on consistent staff reporting. If some professional groups distinguish (as did the physicians in our study) ‘unexpected consequences’ from errors, or if some groups are conditioned to consider Never Events rare, reporting systems may be compromised. Similarly, measurability of the events, which is influenced by the mental models of various professionals towards adverse events, are in turn conditioned by social norms, awareness, and perception of the event itself (
      • Haim A.
      • Chechik T.
      • Zaretzer S.
      • Sher Y.
      • Baniel T.
      • Plakht Y.
      • et al.
      Factors affecting caregivers’ views on reporting adverse events.
      ).
      In our study, nurses perceived themselves as playing a key role in identifying risk and promoting safety in the Operating Room. For example, a recent study found that nurses perceive themselves to be key players in raising concerns regarding quality and safety issues (
      • Martin G.P.
      • Chew S.
      • Dixon-Woods M.
      Uncovering, creating or constructing problems? Enacting a new role to support staff who raise concerns about quality and safety in the English National Health Service.
      ). Therefore, their advocacy for addressing the existence of divergent mental model and providing solutions may be especially important.
      Improvement efforts that can help to address variations in mental models include:
      • Enhancing interdisciplinary and collaborative teamwork by evaluating the discrepancies in the team's mental model and planning a specific intervention to encourage their mutual agreement about the most important characteristics of a Never Event;
      • Tailoring a broader definition of Never Events that reflects the multiple roles of interprofessional teams and characteristics of the surgery;
      • Offering a standardised, interprofessional training around the definition and prevention of errors; and
      • Defining a core of information that must be shared by all clinicians participating in the surgery to improve communication and teamwork.
      This study has several limitations. First, it was conducted at nine Israeli hospitals or at the Israeli Ministry of Health; therefore, the results may not be generalisable to other settings outside of Israel. Second, the findings represent perceptions of managers and not necessarily that of current frontline staff. Third, our qualitative design means that our respondents may not statistically represent the entire population of healthcare professionals.

      5. Conclusion

      This study finds that various mental models around surgical Never Events characterise groups of interdisciplinary professionals. Given the likelihood that mental models emerge from a combination of training and practice common to specific healthcare professions, it is likely that the findings reported here can be generalised to interdisciplinary teams charged with preventing adverse events in other healthcare specialties.
      Further research would benefit not only from the inclusion of more individuals who hold frontline surgical positions but also from querying a larger group of clinicians via a formal survey. Such a study could explore interprofessional differences as well as assess the impact on mental models of the norms of the participating organisation, including any national or cross-cultural differences.
      Finally, follow-up research comparing mental models among clinicians working in environments characterised by different levels of patient safety could further develop the role of mental models in efforts to promote high quality and safe health care.

      Author contributions

      The paper properly credits the meaningful contributions of co-authors and co-researchers.

      Declaration of Competing Interest

      To the best of our knowledge, the named authors have no competing interests, financial or otherwise to disclose.

      Funding

      This study was funded by grant #MOHIG 14-2019 from the Medical Research Fund for Health Services–Jerusalem .

      Ethical statement

      Ethical approval for the study was obtained from the Medical Research and Ethical Committee of the Israel Ministry of Health, reference number 032-2019, on 27 December 2019. Each participant provided verbal consent to participate and received no compensation for their participation. The anonymity of participants was ensured and the data confidentiality was preserved.

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