“Never events” are never supposed to happen. But they do.

JAMA Surgery – “Wrong-Site Surgery, Retained Surgical Items and Surgical Fires, A Systematic Review of Surgical Never Events“:

IMPORTANCE: Serious, preventable surgical events, termed never events, continue to occur despite considerable patient safety efforts.

OBJECTIVE: To examine the incidence and root causes of and interventions to prevent wrong-site surgery, retained surgical items, and surgical fires in the era after the implementation of the Universal Protocol in 2004.

DATA SOURCES: We searched 9 electronic databases for entries from 2004 through June 30, 2014, screened references, and consulted experts.

STUDY SELECTION: Two independent reviewers identified relevant publications in June 2014.

DATA EXTRACTION AND SYNTHESIS: One reviewer used a standardized form to extract data and a second reviewer checked the data. Strength of evidence was established by the review team. Data extraction was completed in January 2015.

MAIN OUTCOMES AND MEASURES: Incidence of wrong-site surgery, retained surgical items, and surgical fires.

Some undesirable things in surgery are unavoidable. Some people will likely get infections no matter how hard we try. Others will have bad outcomes. It’s almost inevitable. But some things are totally avoidable. We should never leave a foreign object in the body, for instance. We shouldn’t operate on the wrong limb. These are called “never events”. But they still occur.

How often? Here’s a systematic review to tell you. They found 138 empirical studies. One hundred and thirty-eight! The wrong site is operated on in about 1 in a 100,000 procedures. Foreign objects are left in the body in about 1 in 10,000 procedures. Why? Often, it’s poor communication evidently.

Now this might not scare you. But then consider that about 50 million procedures are performed in the US each year. As these are called “never events”, they’re occurring far too often. We need to do something. That something, unfortunately, isn’t going to make anyone any money or involve “innovation”, so it’s likely hard to get research on the subject done.


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