Protecting Patients From Medical Never Events

There are no absolutes in the practice of medicine. Diagnoses can be wrong for a number of reasons, complications can arise that couldn’t reasonably be foreseen, infections can set in—a number of variables can cause treatments or procedures to not render the desired results.

Some situations are simply unavoidable; others should never occur. So physicians run multiple tests, seek second opinions, follow established procedures and take all reasonable precautions to protect their patients and themselves.

Still, according to a new Johns Hopkins report, surgical never events occur more than 4,000 times each year.

What is a Never Event?

A never event is something that never should happen, because it is totally avoidable. Such things as performing the wrong surgery on a patient, leaving a sponge, towel or instrument inside the patient’s body or operating on the wrong body part—these are inexcusable errors—errors that should never occur.

As such, these events can leave a practitioner or clinic vulnerable to claims of malpractice, and if the incident really seems to fall into the never category, it can be virtually impossible to defend against.

Proper administrative checks and balances, various levels of review prior to and during a procedure as well as a proactive approach to managing activities can dramatically reduce the chances of such an event occurring.

The study by Johns Hopkins researchers shows that foreign objects are left inside a U.S. patient 39 times per week, while the wrong procedure is performed on a patient 20 times per week. Another 20 times per week, surgery is performed on the wrong body part. Many cases involved operating on the wrong patient.

In 6.6 percent of the 80,000 never events between 1990 and 2010, death resulted; nearly a third of the patients involved suffered permanent injury. These reflect only those cases where a malpractice judgment was issued or an out-of-court settlement was reached. It is reasonably estimated that many more occurrences go undetected or unreported. Each of these incidents is avoidable and should never occur.

How to Best Prevent a Never Event

Many hospitals and clinics, as well as many physicians, have implemented preventive risk-management procedures to ensure that they avoid such situations, such as:

• A careful review of paperwork prior to a procedure to detect anomalies in test results, diagnoses or preparation
• Procedural “time-outs” to ensure that medical records and surgical plans match the patient and the prescribed procedure
• Marking the site of the operation with indelible ink prior to placing the patient under anesthesia
• Detailed sponge, towel and instrument inventories before and after surgery
• Electronic barcodes on materials and instruments to aid in accounting

Having the appropriate procedures in place is only the first step in preventing never events. Those procedures must be uniformly followed and strictly enforced, much like a pilot’s pre-flight checklist. If investigation of an incident shows a lax attitude in following and enforcing those procedures, then for both facilities and practitioners, it can be just as bad as having no procedure at all.

Why Do Never Events Occur?

Because operating rooms and staff are often in great demand, it’s not uncommon for there to be a sense of urgency to vacate the operating room as quickly as possible, so that it can be prepped for the next patient. It’s critical to ensure that adequate time is allowed for an accurate count of all materials and an orderly transition.

It’s also not uncommon for certain critical staff to assist in numerous surgeries throughout the day, sometimes back to back. This makes them subject to fatigue and often rushes them through what should be meticulous pre-verification of patient, procedure and body site, as well as sponge and instrument counts prior to closing.

In some hospitals, it’s not unusual for emergency room and operating room staff members to work 100 hours or more per week, adding still more to their fatigue level and taxing their alertness.

Some surgeons will spend most of a lengthy day, sometimes up to 18 hours, in and out of the operating room, which also takes a toll on their alertness to details.

Complications during a procedure can cause an operation to extend significantly beyond the projected duration, and on busy days, can create a lot of pressure to recover lost time. This puts physicians and assisting staff under stress that can distract them from their tasks at hand.

Ideally, there should be contingency plans in place to provide sufficient flexibility to mitigate that pressure, which can be an important consideration, in the event of a claim.

Long Term Solutions

Certainly, the vast majority of healthcare professionals go to great lengths to ensure their patients receive quality care. Unfortunately, isolated incidents can create an environment in which practitioners can feel as though they’re considered guilty until proving themselves innocent.

This accentuates the need to ensure that comprehensive risk-management procedures are established and followed to prevent a never event from occurring. Such procedures can dramatically reduce the chances of such an incident and can be of tremendous value in defending against a medical malpractice insurance claim.

Never events are typically seen as instances of egregious carelessness or negligence, interpreted as evidence of a disregard for patient welfare when, in reality, they are most often the result of a pressing schedule or fatigued practitioners.

Proactive establishment of preventive risk-management measures and meticulous compliance with such procedures can prevent the vast majority, if not all, of such incidents, as well as offer some level of protection for healthcare professionals and facilities facing malpractice claims.

A failure to adequately address the issue leaves patients, hospitals and healthcare practitioners at great risk. Death, disability, increased discomfort and expense, as well as sanctions and great professional impact are the most common results.

Don’t allow your patients or your practice to be vulnerable to the irreparable damage that a never event can cause. Protect those entrusted to your care and yourself by eliminating avoidable errors.