New study sheds light on common causes of surgical ‘never events’

A new report suggests that many “never events” occur due to a mix of human errors, organizational issues, oversights and rule violations.

When most people prepare for a complex medical procedure, such as surgery, they believe they will receive highly competent care. Unfortunately, this isn’t always the case. According to The Wall Street Journal, one study indicates that thousands of surgical “never events,” or mistakes that should never excusably occur, happen each year. New research has helped reveal some of the underlying reasons for these outrageous and sometimes catastrophic mistakes.

A closer look at never events

WESH News reports that researchers from the Mayo Clinic closely reviewed 69 never events that occurred over a five-year period. These events included wrong-site surgeries, implant mix-ups, retained objects and cases where surgeons performed the wrong procedure. The researchers identified more than 628 factors that contributed to these surgical errors, which could be divided into four categories:

• Outright unsafe actions – these were cases when surgeons broke the rules or failed to adequately evaluate the situation.
• Administrative problems – staffing shortages, poor supervision and inadequate planning were a few examples of these factors.
• Organizational issues – problems with the overall protocols or culture at a facility were grouped into this category.
• Preconditioning factors – these included stress, mental weariness, poor communication, overconfidence and failure to notice broader issues.

After identifying common contributing factors, the researchers suggested that surgical teams more closely monitor mental state, fatigue, time constraints and choice of team members. They also suggested that team members focus on staying vigilant and communicating concerns during each procedure.

Unfortunately, the researchers determined that most errors could not be attributed to one single oversight or mistake. Instead, the average error involved four to nine of these factors. This finding shows why fully eliminating these unnecessary errors remains difficult.

The toll of surgical errors

The prevention of surgical errors remains an important concern because these errors happen surprisingly frequently. During the Mayo Clinic study, never events occurred at a rate of 1 per 22,000 procedures. However, other research that draws on national data points to an error rate of 1 per 12,000 surgeries.

Given the number of surgeries performed each year, never events take a significant toll on public health. The Wall Street Journal states that a Johns Hopkins University School of Medicine study published in 2012 estimates that, across the U.S., 4,000 never events occur annually. The study also found that over half of these errors cause temporary injury, and nearly one-third cause permanent injury.

The toll of never events and general surgical errors here in Maryland is difficult to estimate. According to The Baltimore Sun, hospitals are required to report these incidents. However, some professionals may not understand the reporting requirements. Others may intentionally fail to disclose errors for fear of the consequences. As a result, evaluating the extent of surgical errors, and the number of resulting serious personal injuries, can be challenging.

Victims may have recourse

Sadly, many medical errors, including never events, occur because professionals fail to take preventative actions, such as following hospital protocols. The victims of these negligent mistakes may be able to seek compensation for their expenses, suffering and other long-term complications. In most cases, injury victims may benefit from consulting with a medical malpractice attorney to review their options.

Keywords: medical, malpractice, surgical, error, injury