Surgical never events have the potential for serious patient harm. This prospective study conducted between April 2021 and September 2022 used two approaches (the SEIPS framework and the CARe QI handbook) to explore how work-as-done and system resilience prevent never events in trauma and orthopedic surgery in the UK. Participating healthcare staff identified systems-level approaches to improve safety. Researchers observed a significant increase in mean time between the incidence of never events (from 46 to 224 days).