Data Shows U.S. Never Events Occurring More Frequently

January 17, 2013 (Press-News.org) A media outlet that reports of a story about a man who had the wrong arm amputated or a woman who had a surgical tool left inside her after surgery may seem like astonishing news stories that hardly ever occur. However a new study conducted at Johns Hopkins hospital says these types of "never events," as they are called, actually happen more frequently than most people think.

What is a never event?

"Never events" are events that occur in hospital settings that are inexcusable and should simply never occur. A list of 28 never events were compiled by the National Quality Forum and include events defined as serious and largely preventable. A foreign object left inside a patient body is one such example.

The results of the study

Researchers at Johns Hopkins recently conducted a study on never events and found alarming results. After examining malpractice judgments and settlements found in the federal repository known as the National Practitioner Data Bank (NPDB) throughout the country between 1990 and 2010, researchers estimate that over 4000 never events occurred during this time period.

According to the data, researchers determined that a foreign object was left inside a patient's body after surgery about 39 times a week during this period. Additionally, the data revealed that the wrong procedure or wrong part of the body was operated on about 20 times a week.

The data also shows that these events tended to occur among the same surgeons. About 62 percent of surgeons were cited in more than one medical malpractice incident.

The alarming rate of occurrence

These never events should never occur but do and frequently. And, according to study leader and associate professor of surgery at Johns Hopkins University School of Medicine Marty Makary, they probably happen even more than the data suggests. He says hospitals are to voluntarily disclose never events that occur at their location to the Joint Commission--a non-profit organization that endorses hospitals that meet certain performance standards--but this doesn't always happen.

Makary says that it's understandable that problems like infections in healthcare settings exist, but never events are totally preventable and should never take place.

Proactive measures to reduce never events

Some hospitals, Makary says, are taking measures to reduce these occurrences. Mandatory timeouts are being implemented where medical records and surgery game plans are examined prior to the start of an operation. Also, certain hospitals are utilizing what's known as indelible ink (a form of permanent marker that can't easily be washed away) that marks the exact site of the surgery. Counting all surgical instruments, including sponges and gauze, before and after the operation to avoid any accidentally left inside a patient is also being done.

Some hospitals are taking a step further and using high tech electric bar codes. These electronic bar codes are provided on instruments and other tools used during surgery and are being utilized to prevent never events from occurring.

Hopefully, other 21-century technology will become available on the market in the years to come to help reduce these occurrences even further.

Article provided by Law Offices of David J. Hernandez & Associates
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