The wrong ear was implanted. A needle was left in the child’s neck. A man is septic from retained nasal packing after sinus surgery. A woman’s face is burned after a fire fueled by prep solution. A healthy baby coded in recovery after tympanostomy tube insertion. Otolaryngologists believe these events could never happen in their operating room. Yet never events such as wrong site surgery, wrong patient surgery, unintentional retained foreign objects, operating room fires, or immediate postoperative death in a healthy patient are more common than they should be in head and neck surgery. Even in the absence of a distinct never event, these factors periodically align to result in near catastrophic patient outcomes. Such events are caused by a myriad of interacting elements including systems deficiencies, human factor or decision-making errors, and team failures. Near misses, sentinel events and horrific complications affect patients and families often irreversibly. They also increasingly draw scrutiny to surgical practices and systems, surgeon technical competencies, and evidence-based decision-making. In the last decade numerous programs or hospitals have been gravely impacted by the failure to prevent, recognize, or respond to major surgical errors or complications. In this audience-interactive panel, we present real-life cases that went wrong, how these problems were addressed, and potential solutions to avoid or mitigate these crises in the future. Through these case presentations we emphasize key principles of root cause analysis, health system safety, institutional safety culture, and quality improvement interventions to address these types of events in otolaryngologic surgery.