Beginning with the Institute of Medicine’s report, To Err

is Human,1 published more than a decade ago, there has been an increasing national emphasis on patient safety and surgical quality. This has been manifest in linking reimbursement to quality as well as in the increase in funding and resources geared toward looking at compara-tive effectiveness and outcomes in health care as mea-sures of patient safety and quality.2 Different methodologies have been used to measure and report patient safety events, including incident reporting sys-tems, manual medical error review, and administrative data.3 To standardize a method to detect potentially pre-ventable and harmful events, the Agency for Healthcare Research and Quality (AHRQ) has developed patient safety indicators (PSIs), which use software to identify potential adverse events using International Classifica-tion of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes.4 These PSIs are designed to screen for medical errors resulting in a potential compromise to patient safety, thus helping hospitals identify areas of potential improvement. However, PSIs are not designed to include all pre-ventable and adverse events. There remains a need for health care facilities to continue to report events that are amenable to systematic learning and improvement. “Never ” events are serious reportable medical errors that result in a serious compromise in patient safety and are considered completely preventable. The National Quality Forum has defined 28 events divided into the following categories: surgical, device, care management, patient protection, environmental, and criminal events. Within surgical care, these events include surgery performed on the wrong body part or on the wrong patient, the wron