

Events that should never occur in surgery (“never events”) happen at least 4,000 times a year in the U.S. according to research from Johns Hopkins University.

The findings, published in Surgery, is the first of its kind to reveal the true extent of the prevalence of “never events” in hospitals through analysis of national malpractice claims. They observed that over 80,000 “never events” occurred between 1990 and 2010.

They estimate that at least 39 times a week a surgeon leaves foreign objects inside their patients, which includes stuff like towels or sponges. In addition surgeons performing the wrong surgery or operating on the wrong body part occurs around 20 times a week.

Marty Makary, M.D., M.P.H., an associate professor of surgery at the Johns Hopkins University School of Medicine, 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. 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.”

The researchers believe that this finding could help ensure that better systems are developed to prevent these “never events” which should never happen.

The study examined data from the National Practitioner Data Bank which handles medical malpractice claims to calculate the total number of wrong-site-, wrong-patient and wrong-procedure surgeries.

Over 20 years. they found more than 9,744 paid malpractice claims which cost over $1.3 billion. Of whom 6.6% died, while 32.9% were permanently injured and 59.2% were temporarily injured.

Around 4,044 never events occur annually in the U.S., according to estimates made by the research team who analyzed the rates of malpractice claims due to adverse surgical events.

Many safety procedures have been implemented in medical centers to avoid never events, such as timeouts in the operating rooms to check if surgical plans match what the patient wants. In addition to this, an effective way of avoiding surgeries that are performed on the wrong body part is using ink to mark the site of the surgery. In order to prevent human error, Makary notes that electronic bar codes should be implemented to count sponges, towels and other surgical instruments before and after surgery.

It is a requirement that all hospitals report the number of judgments or claims to the NPDB. Makary did note, however, that these figures could be low because sometimes items left behind after surgery are never discovered.

Most of these events occurred among patients in their late 40s, surgeons of the same age group accounted for more than one third of the cases. More than half (62%) of the surgeons responsible for never events were found to be involved in more than one incident.

Makary comments the importance of reporting never events to the public. He stresses that by doing so, patients will have more information about where to go for surgery as well as putting pressure on hospitals to maintain their quality of care. Hospitals should report any never events to the Join Commission, however this is often overlooked and more enforcement is necessary.

Written by Joseph Nordqvist