Thousands of Surgical “Never Events” Occur Each Year, Study Finds

An estimated 80,000 surgical “never events,” – events that should never happen during surgery according to universal professional agreement – occurred in American hospitals between 1990 and 2010, researchers at Johns Hopkins reported in the journal Surgery. They suggest that documenting the problem will help health care professionals take a step toward developing better systems to prevent surgical mistakes.

Researchers used a federal repository of medical malpractice claims to identify 9,744 claims and judgments that totaled $1.3 billion over 20 years. Using these published rates, the researchers estimate that more than 4,000 surgical never events occur in the United States each year.

The study estimates that a surgeon leaves a foreign object such as a towel inside a patient’s body after an operation 39 times a week, performs the wrong procedure on a patient 20 times a week and operates on the wrong body part 20 times a week. Sixty-two percent of the surgeons named were cited in more than one separate malpractice report.

“The events we’ve estimated are totally preventable,” says study leader and associate professor of surgery at the Johns Hopkins University School of Medicine Marty Makary, M.D. M.P.H. “This study highlights that we are nowhere near where we should be and there’s a lot of work to be done.”

Hospitals are required by law to report to the NPDB never events that result in a settlement or judgment. The study assumes that their estimates of never events are low because health care professionals do not discover all items left behind after surgery, as these mistakes are typically found only when a patient experiences complications after surgery.

Common patient safety procedures have long been in place to prevent never events. These include a mandatory “timeout” before an operation to ensure medical records and surgical plans match the patient on the table. Other efforts involve procedures to count surgical items before and after surgery and the use of indelible ink to mark the surgery site beforehand. Some hospitals now use electronic bar codes on surgical materials to prevent human error.

Along with more foolproof procedures to prevent never events, Makary believes better reporting systems are also necessary. He suggests public reporting of never events, an action that would give consumers the information to “put hospitals under the gun to make things safer.”

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