Published on:

“Never Events” in the Operating Errors Still Occur

Certain major errors during surgery are so rare that they are called “never events”. While such medical errors are rare, they do continue to occur in hospitals across the country.
According to a new review of surgical errors published in the JAMA Surgery Journal, approximately one out of every 100,000 surgeries involves a wrong site error. In a wrong site error, the doctor either operates on the wrong side of the patient’s body, on the wrong body part, or even on the wrong person.

The good news is that these “never events” are very rare. The bad news is that there is very limited data on these errors, which makes devising strategies to control them very challenging. For example, researchers had very little data available on the number of fires that break out in operating rooms during surgery. When there are only a few rare events, data collection is difficult, and researchers find it more challenging to develop strategies to prevent these errors.

However, researchers believe that one of the causes of such “never events” in operating rooms is miscommunication, or lack of communication among staff members. A surgical checklist can help reduce much of the risk involving never events. A surgical checklist must be used before, during and after the surgery, and is a valuable tool to specifically identify the site of the patient’s body that must be operated on, the identity of the patient, and other details that can help eliminate the chances of a “never event”.

The use of a surgical checklist can also help prevent errors that involve foreign objects left behind in the patient’s body during surgery. According to the review, such foreign body retention occurs in approximately one out of every 10,000 procedures. A quick count of all medical sponges and other instruments used in the surgery, both before and after the surgery, can help prevent the risk that such foreign objects will be left behind in the patient’s body.

It is important to devise better tracking and monitoring methods to identify the risk of never events in the operating room. It’s also important to identify near-miss events, in which potentially dangerous errors are made, but don’t injure patients because they’re caught in time.By doing this, hospitals and healthcare providers can provide excellent and safe care for their patients, which is the ultimate goal.