The generic surgical never event fishbone was developed by Dr Jane Carthey. It is based on the findings from previous never event investigations and published literature on the underlying causes of surgical never events.

The fishbone diagram captures the team, organisational & strategic, task, patient, communication, education & training, equipment, working condition and individual staff factors that increase the risk of surgical never events.

How can I use it?

The generic surgical never event fishbone diagram can be used in many ways:

  • As an educational tool – use it as a platform to have conversations with theatre teams, managers and NHS Boards about the causes of surgical never events.
  • During incident investigations – incident investigation leads can use it to check their investigation has identified human factors issues like team psychological safety, fixation and workload.
  • Conversations with NHS Boards and CCG leads – to explain the multi-factorial nature of surgical never events and in particular, the systems and cultural issues that need to be addressed to prevent them.
  • As a proactive tool – theatre teams can use it during debriefs and audit days to appraise the level of risk in a given operating theatre, and to develop solutions to resolve emerging safety threats.

Who can use it?

The generic surgical never event fishbone diagram was developed to share with healthcare organisations in the spirit of learning and improvement. Please cite Dr Carthey as the author and feel free to share it with anyone who may find it a useful tool.

Providing feedback on how you use it

Please contact Dr Jane Carthey ( with any feedback or examples of how you have used the generic surgical never event fishbone diagram. [Download PDF here or click on thumbnail below]





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