Errors occurring in healthcare annually have contributed to the increase in cost of additional treatments and length of stays. Public awareness of the human toll of these errors has increased with required reporting to government and regulatory agencies. Healthcare organizations have looked to industry with high levels of safety culture, teamwork, and communication, to provide the evaluation tools and system changes to mitigate these errors. This specific healthcare organization comprised of nine hospitals utilized the Safety Attitudes Questionnaire (SAQ) as a measure of safety culture, teamwork and communication and the relationship of these on surgical never events of retained foreign objects and wrong side/site surgery. The SAQ was administered to the surgical team twice over a 2 year period. The results demonstrated increased team satisfaction but not a decrease in surgical errors. Culture changes must accompany system changes in order to reduce the occurrence of surgical errors.