Home E-Weekly June 16, 2015

Still Too Many Never Events

Published: June 15, 2015

Wrong procedures, leaving items behind in patients and OR fires — surgery's "never events" — might not happen often, but they happen often enough to cause concern, according to a study published in JAMA Surgery.

The researchers analyzed 138 studies conducted between 2004 — the year the Joint Commission's Universal Protocol was introduced — and June 2014 that involved incidence reporting of these 3 never events. Wrong-site surgery occurred 0.09 times per 10,000 procedures and retained items 1.32 events per 10,000 procedures. The incidence of surgical fires was unknown.

According to the researchers, communication problems were the most frequent cause of wrong-site surgery, accounting for 21% of 672 identified root causes. Retained surgical items were caused by a variety of risk factors, notes the study, including patients' body-mass indexes, inadequate staff communication and incomplete or undocumented counts. Surgical fires, say the researchers, were caused by a lack of awareness of fire risks and surgical teams' failures to communicate.

The study's tabulations translate into approximately 500 wrong-site surgeries and 5,000 retained items occurring each year based on an estimated 50 million surgeries performed annually.

Although few studies of interventions that prevent never events have been conclusive, the researchers say their findings suggest inadequate staff communication is the underlying cause of most surgical errors. They also wonder whether error occurrence can be reduced to zero to achieve a true never-event rate. To enhance patient safety efforts, the study's authors call for improved evaluation of how mistakes in the OR occur and renewed focus on what can be done to prevent the "too-many events" they discovered.

Daniel Cook

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