So-called ‘never events’ include operating on the wrong body part or leaving towels inside patients
At least 4,000 surgical errors called “never events” occur in the United States each year, according to a new study.
Never events are mistakes that should never happen during surgery, such as leaving objects inside patients, performing the wrong procedure and operating on the wrong side of the body, the Johns Hopkins researchers explained.
They analyzed national data and estimated that 80,000 never events occurred in U.S. hospitals between 1990 and 2010, and believe that figure may be on the low side.
They also estimated that U.S. surgeons leave a foreign object such as a sponge or a towel inside a patient’s body after an operation 39 times a week, perform the wrong procedure on a patient 20 times a week, and operate on the wrong part of the body 20 times a week.
Never events were most common among patients aged 40 to 49. Interestingly, surgeons in the same age group were responsible for more than one-third of never events, compared with about 14 percent for surgeons older than 60, according to the study published online in the journal Surgery.
Documenting the scope of the problem is an important step in developing ways to prevent never events, the researchers said.
“There are mistakes in health care that are not preventable. Infection rates will likely never get down to zero, even if everyone does everything right, for example,” study leader Dr. Marty Makary, an associate professor of surgery at the Johns Hopkins University School of Medicine, said in a Hopkins news release.
“But the events we’ve estimated are totally preventable. This study highlights that we are nowhere near where we should be and there’s a lot of work to be done,” he noted.
Many hospitals have long had safety procedures to prevent never events, such as “timeouts” in the operating room before surgery to make sure that medical records and surgical plans match the patient on the table, Makary said.
Other measures include using indelible ink to mark the surgical site before the patient goes under anesthesia, and counting sponges, towels and other surgical items before and after surgery.
But these precautions are not foolproof, according to Makary.
Many hospitals are beginning to use electronic bar codes on surgical instruments and materials to ensure precise counts and prevent human error, the release noted.