Understanding never events: developing an ecologically valid behavioral test for left-right confusion during surgery

Introduction: The accurate distinction between left and right is a critical cognitive function. A failure to correctly distinguish left and right during surgery can lead to a so-called Never Event, a preventable medical error that leads to death or severe injury of the patient. Unfortunately, such wrong-site surgeries still happen every year. Thus, understanding left-right confusion during surgery is critical for patient safety. However, current Left-Right Confusion (LRC) tests have low ecological validity for the complex, time-critical demands of a surgical environment. This study introduces the Never Events in Surgery Test (NEST), a novel, ecologically valid behavioural paradigm designed to simulate the cognitive dynamics during surgery. Methods: = 108) completed the NEST alongside established LRC tasks: the Bergen Left-Right Discrimination Task (BLRDT), the Left-Right Commands Task (LRCT), and the Left-Right Questionnaire (LRQ). Crucially, the study established a cognitive dissociation: while reaction times across tasks were correlated, reflecting a shared component of general processing speed, the error rates from the established LRC measures (BLRDT, LRCT, LRQ) failed to predict the error rate observed in the applied NEST paradigm. Discussion: The lack of predictive power for errors suggests that LRC susceptibility in applied contexts is an independent, context-specific risk factor for laterality errors not captured by traditional assessments. The findings argue for a paradigm shift in training and screening toward tailored, context-specific approaches.