A recent study found that over 4,000 surgical “never-events” occurred on average each year from 1990 to 2010 in the United States.
A never-event is categorized as an error that should never occur, like leaving a surgical sponge inside a patient or operating on the wrong appendage.
Researchers estimate that never-events cost healthcare systems millions of dollars each year in malpractice suits. The authors of the findings said the greater focus is being placed on preventing never-events, but the numbers highlight a dangerous trend.
“In an effort to incentivize patient safety in surgery, payers are increasingly focusing on these events that should never take place (surgical never events) as metrics of quality care,” the researchers wrote. “Medicare and several states have already announced that hospitals will be penalized for such events in pay-for-performance programs.”
The authors reviewed data provided by the National Practitioner Data Bank. Based on literature claim estimates, the authors found that an average of 4,082 never-events occurred each year between 1990 and 2010. That means more than 11 events that should never happen during surgery occur each day.
Of the physicians involved, 62% were listed in multiple malpractice reports, while 12.4% of physicians were named in multiple never-event malpractice reports.
The study also found that physicians aged 50 to 59 were more likely to have multiple never-event claims than those surgeons younger than 40 years old.
Although the number is alarming, researchers believe the actual number is probably higher due to limitations such as underreporting of never-events, claims settled by corporate entities, and lack of data on certain types of surgeries.
Researchers said a strong emphasis among multiple organizations needs to be placed on preventing surgical never-events.
“For a fraction of the costs associated with surgical never-events, we can monitor patterns of these errors better and ultimately discover effective approaches to eliminating them.”
Dr. Silverman Comments
“Never-event” errors are disturbing. When surgeons hear about others committing never-events we say to ourselves, “how did they do that?” and “I’m never going to do that.”
These types of errors are all too common, and it is troublesome for both surgeon and patient. Some people may even avoid having corrective surgery out of fear of having a never-event happen to them, even if postponing the operation may be detrimental to their health.
Every surgeon knows another surgeon he/she respects who has committed a never-event. I know doctors who have fused the wrong ankle, operated on the wrong hip, worked on the wrong level in the spine, fixed the wrong knee, and numbed the wrong leg. They are all excellent doctors that I would trust operating on myself or my family, but something happened to distract them at the wrong moment. In most cases, flipping the patient from supine (on the back) to prone (on the belly) is a routine source of confusion.
The World Health Organization has developed a three step system to help reduce surgical mistakes. The three phase approach focuses on three important steps during the surgical process. Surgeons are encouraged to go through a checklist before administering anesthesia, before the incision, and before the patient leaves the operating room. I believe we will see a significant drop in errors once the WHO system is more routinely accepted across the country. Taking time to review is going to save lives.
Related source: Medscape
