"Never Events" –80 Times Per Week?!

Surgical instruments AMedNews.com recently reported on the occurrence of surgical “never events” –events so severe and egregious that they should never happen. Never. But, never say never, because never happens, in this case, on average, about 80 times per week.

Never events include leaving an instrument in a patient, operating on the wrong body part, the wrong patient, or doing the wrong procedure. The fact that these events are happening about 80 times per week was discovered by a review of settlements and judgements from 1990-2010 in the National Practitioner Data Bank. Overall, there were about 10,000 never event cases found with settlements totaling $1.3 billion. The good news is that despite these arguably high numbers, when compared to the number of surgeries performed each year, the appearance of a never event is only one in 12,248 procedures. But, even one in 12,248 is too many, because these errors are so extreme. Luckily, two-thirds of the cases only saw a temporary injury. But, one-third of cases saw a permanent injury.

All of this, despite the Join Commission’s 2004 mandate for a three-step universal protocol to prevent wrong-patient and wrong-site surgeries.

Interestingly, the errors happened broadly across the age spectrum. Many may have thought that it was the younger surgeons or the older surgeons who might be more suceptible to such errors, but no one is immune. Another interesting thing to note was how the average amounts of payouts varied by type of error. Conducting the wrong procedure resulted in the largest payout: $232,035, followed by the wrong site: $127,159, the wrong patient: $109,648, and retained a foreign body: $86,247. But, what is the difference is between the “wrong patient” vs. the “wrong procedure?”

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