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Two studies reviewed Never Events to identify factors and consequences associated with preventable medical errors.

Never Events are egregious medical errors that should never occur.  There are seven categories of Never Events that include surgical, device, patient protection, radiologic, environment, criminal and care management events. Recently two published studies took a deeper look into the contributing factors and outcomes of surgical Never Events.

The first study, published in The Joint Commission Journal on Quality and Patient Safety, looked at data from claims for wrong-site surgery between the years 2013 and 2020. Wrong site surgery (WSS) is the term used for surgical mistakes involving surgery on the wrong part of the body, the wrong patient, the wrong side of the body, or the wrong procedure on a correctly identified body part.

In reviewing 68 closed claims, the most common procedures associated with WSS include:

  • Spine and intervertebral disc procedures
  • Arthroscopy
  • Surgical procedures on muscles and tendons, such as hand surgery

On these claims the most common type of injury that resulted from WSS included (in order):

  1. Additional surgery
  2. Pain
  3. Mobility dysfunction
  4. Exacerbation of injury
  5. Death

Importantly, the factors that led to these injuries were pretty straightforward: failure to follow policy (83.3 percent) and failure to review medical records (41.4 percent).

A second study published in BMC Patient Safety in Surgery, used machine learning to identify risk factors following surgical error. In this study, researchers used three machine learning models to evaluate 9,234 safety standard observations and 101 root cause analysis of actual Never Events.  The investigation found that the majority of Never Events occurred in six areas including (in order) General Surgery, Gynecology, Orthopedics, Cardiology/Cardiothoracic, Ophthalmology, and Urology.

The study also developed a list of the most common factors that contribute to Never Events.  Some of those factors include:

  • Faulty verification of surgical items, including item counts
  • Procedure in small rural hospital
  • Lack of out loud verification of patient and procedural details
  • Lack of out loud verification of consent forms
  • In Orthopedic settings, a shorter surgery length of one to two hours increased the odds of a Never Event, possibly because surgical teams may skip checklist items.
  • During short Ophthalmologic procedures, wrong site surgery was more likely to occur when two nurses are present.

Researchers noted that the use of standardized surgical count and safety checklists has not significantly impacted the number of Never Events.  It was suggested this is because Never Events are oftentimes related to human error more than system error.

These studies reveal the depth and severity of Never Events.  As well, machine analysis may provide a new perspective on the surgical and procedural formats that are most likely to injury the patients they were intended to help.

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