MDNews - Greater Boston

speCial Feature A Trip to Never Event land conserVatiVe data suggests surgical neVer eVents occur in the united states at least 4,000 times annually, and these incidents haVe sobering conseQuences for surgeons, patients, hospitals and public health officials. new research implies possible freedom from these errors — and the malpractice suits that may result from them. T the road to never Dr. Makary, who recently led an analysis of malpractice claims related to never events that rendered the base estimates for the number of these occurrences, believes more practices — such as surgical timeouts and checklists and improved technology, such as radiofrequency tags on sponges — in conjunction with improved reporting systems can contribute to improved safety. "The effect we've seen for preventing errors is that whenever a problem is measured well and publicly reported, hospitals tend to approach their front-line care providers and ask what [the facility] needs to do to fix it," he says. "Right now, reporting for never + during that time frame, state licensing boards + 4,000 never events occur each year. events is very haphazard, invoked disciplinary actions against 10% of physi+ 49.8% of never events occur when a foreign but if we can standardize cians involved in surgical never events. object remains in the body after surgery. it, we can better measure + 6.6% of patients who experienced a never event + Performing the wrong procedure accounts for the magnitude of the died as a result. 25.1% of never events. problem and motivate + 32.9% of patients who experienced a never event + 24.8% of never events are classified as wrong-site. hospitals to begin that were permanently injured. + the average malpractice payment for a never dialogue." + 96% of surgical never event legal matters were event from 1990 to 2010, adjusted to 2012 dollars, Because improvesettled out of court. was $140,095. ment comes from not the reporting itself but Source: "Surgical Never Events in the United States," Makary, et al., January 2013 issue of surgery rather changes implehey Are cAlled "never events" because, theoretically, they should never happen. Performing surgery on the wrong patient, on the wrong part of the body or without removing foreign objects from the body following the procedure — these are simple human errors the Centers for Medicare & Medicaid Services (CMS) deems "reasonably preventable by following evidence-based guidelines." Nevertheless, these errors have consistently plagued operating rooms despite the growth of patient safety organizations and heavy fines for malpractice. "Physicians and surgeons have the wisdom to engineer hospital processes to be more reliable, but the systems in which they operate rarely solicit their input, rendering the field largely incapable of learning from mistakes," says Marty Makary, M.D., M.P.H., surgeon with Johns Hopkins Medicine, associate professor at Johns Hopkins Schools of Medicine and Public Health, and author of The New York Times best seller Unaccountable. "For the first time, we're measuring the magnitude of the never event problem, and that's step one for helping patients and preventing future never events." n e Ver e Vents by th e n u m b ers 8 | Greater Boston MD News ■ MdneWS.coM

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