Archive February 2014 XV, No. 2

Zero Tolerance for Never Events

Can we get to zero? Yes, experts say it can be done.

Jim Burger

Jim Burger, Senior Editor


wrong-site surgeries NO MISTAKING One of the best ways to prevent wrong-site surgeries is to have surgeons cut through the word yes or their initials.

For most surgeons, wrong-site surgery is an abstraction — something that could happen, but hasn't, at least not to them. Unscathed by misfortune, they walk between raindrops, insulated from the deep regret such a slip-up can cause.

David Ring, MD, isn't as lucky. It's been more than 5 years since an unlikely series of events led him to perform a carpal tunnel release on a Spanish-speaking patient who'd been admitted for a trigger-finger release — a personal trauma he later chronicled in the New England Journal of Medicine ( For Dr. Ring, the memory is still haunting. "For somebody who's done a wrong procedure, it's a lifetime of doing anything you can to prevent it from happening again," he says.

Such mistakes are called never events — wrong site, wrong patient, objects left behind and so forth — but is that a misnomer? With thousands of procedures performed every day, each with hundreds of attendant variables, is never a realistic goal? "It absolutely is," insists Spence Byrum, an expert on high-reliability organizations and a managing partner of Convergent HRS in Weston, Fla. "How can it be anything else? These are patients' lives and well-being. It's like a pilot saying I hope I get 9 out of 10 of these landings right."

Of course, setting a goal and achieving it aren't the same, but the experts we talked to firmly believe that with the right tools and the right attitudes, surgical facilities can get a lot closer to zero than they are now.

Where it begins
The process starts — or should — long before the procedure takes place, says Mr. Byrum. "A disproportionate number of wrong sites have their origins in the physician's office," he says. "It could be an incomplete handoff, it could be H&Ps or consents that are not signed. Any time you're dealing with labs, MRIs, CTs, X-rays — if you're trying to make everything come together just before the surgery, it's very difficult. Really, that patient should not be in the OR if you don't have those things complete. Otherwise you're absolutely compressing your window to make sure you get everything correct."

That rushed approach — what Mr. Byrum calls time compression — is one of the most significant risk factors, he says. Once you fall behind, the threat rises.

"The first case of the day is very, very important. It's your best chance to start on time," he says. "Anything after that that isn't on time introduces complexity. So having subsequent cases lined up, ready with all the appropriate information, is critical, because as the schedules start to slide, then other people come in, patients or instruments aren't in the room, and so on. All of those things are risk factors."

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