Health Care

How can we prevent 'never events'?

May 29, 2013
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Everything has risks. This is especially true in health care.

For example, surgical errors occur more than frequently in the U.S.

"Never events"

Things that should never occur in surgery happen at least 4,000 times annually, according to recent research from Johns Hopkins University.

These findings were the first to reveal the extent so-called "never events" in hospitals through analysis of national malpractice claims.

More than 80,000 never events occurred between 1990 and 2010.

Foreign objects and being wrong

It is estimated that at least 39 times each week, surgeons leave foreign objects inside their patients, things like towels or sponges.

About 20 times each week, some surgeons perform the wrong surgery or operate on the wrong body part.

Even if everyone does things perfectly, there is no way to completely avoid some things like infections.

However, understanding and admitting errors can lead to ways to minimize the risks.

Malpractice claims

The National Practitioner Data Bank was examined to look at medical malpractice claims and calculate the number of wrong site, wrong patient and wrong-procedure surgeries.

Over the past 20 years, researchers found more than 9,744 paid malpractice claims, which cost over $1.3 billion — where 6.6 percent died, 32.9 percent were permanently injured and 59.2 percent were temporarily injured.

All hospitals are required to report the number of judgments or claims to the National Practitioner Data Bank. However, that these figures may be low, because sometimes items left behind after surgery are never discovered.

Prevention

Many medical centers have implemented safety procedures to avoid never events.

These include timeouts in operating rooms to check if surgical plans match what the patient wants.

To avoid surgeries on the wrong body part, ink is used to mark the site of the surgery.

Electronic bar codes can be implemented to count sponges, towels and other surgical instruments before and after surgery.

Michigan is one of the leading states in addressing and preventing problems.

Keystone Center

The Keystone Center, led by the Michigan Health & Hospital Association in collaboration with many others, is a bright spot that receives national attention.

Patients need to have more information about where to go for surgery, as well as to put pressure on hospitals to maintain their quality of care.

Public awareness is needed in order for people to make reasonable and knowledgeable decisions in consultation with their providers. 

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