Oct 03

Never Events Should Never Happen

A “never” event is one which should never occur, and is a term which brings profound unease to patients. In other words, when a disturbing medical event which should never happen does happen, the medical community deems it a “never” event. In fact, there even exists an NHS England Surgical Never Events Task Force Report on the subject. This report concludes that never events are most commonly reported in surgical procedures. Typically, never events include wrong site, wrong patient, wrong procedure.

This means that the wrong patient underwent a surgical procedure not intended for him or her, a patient underwent a surgical procedure on the wrong site (left side instead of right side, etc.), or the wrong procedure was performed on the patient (a tonsillectomy rather than a pacemaker implant).

Never events can lead to extremely serious, extremely adverse outcomes. Further, these never events can severely damage the trust and confidence patients place in their doctors, nurses and other medical professionals.

Some Examples of Never Events

Examples of never events reported to the Minnesota Department of Health included:

  • Nearly 40 percent of never events concerned pressure ulcers or bedsores.
  • About 30 percent of never events concerned patient falls while hospitalized.
  • About 12 percent of never events were for retained foreign objects following a surgical procedure.
  • Seven percent of never events were for a surgical procedure at the wrong site.
  • Five percent of never events were for a wrong medical procedure.
  • Two percent of never events were for medication errors.

Seventy-one percent of never events across the nation are fatal, whether immediately or later when the even causes medical complications for the patient. Medicare has made the choice to no longer pay for any of the additional costs related to preventable errors or never events.

Foreign Objects Left in the Body Following a Surgical Procedure

Objects left inside a patient’s body following a surgical procedure are also considered never events, however between 2012-2013 alone, Strategic Health Authorities reported 130 instances of post-op retained foreign objects. These foreign objects can include instruments, sponges, surgical swabs, guidewires, and even needles.

Despite a formal counting/checking process, foreign objects continue to turn up in patients’ bodies months or years later. Some hospitals are going to a barcoded system to help prevent this particular never event, however since operating rooms tend to be high-stress environments, it will take time—and technology—to ensure foreign objects are never left inside a patient.

Communication is Key

In addition to surgical procedures handled in hospital operating rooms, day surgeries and procedures performed in day care units also experience never events. Human factors are the overarching challenge in never events. Humans must interact with technology, must function with their team, and must engage in clear communication.

The interactions between the human and the medical device is critical, and should leave no room for misunderstanding. Communication must be clear and precise between medical professionals to minimize the potential for misunderstanding, misreading or misinterpreting a conversation, or even distracted communications.

The success of a surgical procedure depends heavily on skilled professionals executing a delicate, balanced, precision “dance” which begins with diligent planning and rehearsal. Never events are quite often the result of lack of planning, lack of briefing medical professionals prior to the surgery, unfamiliar or differing approaches, or a failure to carry out comprehensive checks. When complacency sets in, or there is not the required double-checking and rechecking, never events can occur.

Solutions to Never Events

Proposed solutions to never events include:

  • A systematic training and education program for all those involved in surgical procedures
  • The standardization of operating room procedures
  • Providing activities in surgical areas which support patient safety

How an Oregon Medical Malpractice Attorney Can Help

If you or a loved one has suffered a never event, it could be extremely beneficial to speak to an Oregon medical malpractice attorney as quickly as possible to avoid limiting your ability to file a claim due to the statutes of limitations. Keith Dozier and his associates have successfully recovered millions for injured patients in Portland, Vancouver, Lake Oswego, Salem, and throughout the state of Oregon. Call us today at (503) 594-0333 for a free initial consultation and review of your case. Do not face this serious medical issue alone—speak to an experienced Oregon medical malpractice attorney today.

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