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Why Do Surgical “Never Events” Continue to Happen?

Dr. Ken Kizer, former CEO of the National Quality Forum (NQF), coined the term “Never Event” in 2001 to refer to medical errors that should never happen but do, alarmingly often. The surgical Never Events Dr. Kizer and his group cited were:

  • Surgery performed on the wrong body part
  • Surgery performed on the wrong patient
  • Wrong surgical procedure performed on a patient
  • Unintended retention of a foreign object in a patient after surgery
  • Intraoperative or immediately postoperative death of a normal, healthy patient

Since then, much study has gone into the problem of these events and potential reforms to hospital protocols that could eliminate them. Most recently, a Mayo Clinic study of 22,000 procedures identified 69 Never Events and 628 factors that contributed to them. The factors fit into four broad categories:

  • Organizational influences — Factors suggesting that the culture of the hospital allowed for errors
  • Oversight and supervisory factors — Inadequate supervision allowing an error to occur
  • Unsafe actions — The error itself
  • Preconditions for actions — The status of the surgical team prior to the procedure

The study showed that organization and supervision rarely played a role in the occurrence of Never Events. That may be due to the aggressive way many hospitals have addressed such events over the last decade on the systems level, creating and enforcing stricter surgical protocols. The study also indicated that the unsafe action rarely involved an outright violation of a standard protocol by a member of the surgical team. Rather, it involved cognitive errors and bad judgment, such as confirmation bias — an assumption that something must be okay because someone checked it.

What makes highly trained professionals vulnerable to confirmation bias? The answer may be in the fourth category. What is going on with the surgical team as they approach the procedure? Is everyone well rested? Are they confident? Do they trust each other? Do they communicate well? These very human factors seem to be why it has been so difficult to eliminate Never Events, and why that label may never be literally true.

A Never Event is always a sign of negligence. If you or a loved one has sustained an injury due to a surgical Never Event, contact an experienced medical malpractice attorney at Rudberg Law Offices, LLC.

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