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What Is a Medical “Never Event”?

I've spent half a century (yikes) writing for radio and print—mostly print. I hope to be still tapping the keys as I take my last breath.

More than 50 million surgical procedures take place every year in the United States. Inevitably, something will occasionally go wrong. It happens less than 0.0001 percent of the time, but, because of the volume of surgeries that adds up to 4,000 “never events” happening each year, almost three quarters of them are fatal.

They are also called “sentinel” events, described as any occurrence “in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness” (The Joint Commission).

Wrong-Site Surgery

Statistically, an individual hospital in America can expect to see a never event once every five to 10 years; that’s a frequency of about 1 in every 112,000 surgical procedures. While botched surgery is rare it’s still catastrophic for the patient.

Wrong-side surgery happens when a wrong body part is operated on, such as a left knee replacement being performed when it should have been the right side knee. A British study published in March 2020 found that “A total of 86 wrong-site/side list errors were identified in 29,480 cases (0.29%).” The study team report that the “Incidence has remained static despite the mandatory introduction of surgical checklists.”

Deborah Craven, 60, was in Yale New Haven Hospital for the removal of a pre-cancerous lesion on her eighth rib. Radiologists had clearly marked the rib for removal. After the surgery, Ms. Craven was still in pain and an x-ray revealed her eighth rib was still in place; the surgeon had removed the seventh rib. The patient had to undergo a second surgery to correct the error.

A malpractice lawsuit followed and the hospital settled.

Retained Foreign Bodies

It ought to be simple. How many sponges did we have before the surgery and how many do we have after? Sometimes, the numbers aren’t the same and the missing item turns out to be still inside the patient. In the jargon of the medical trade, this is called an “unintended retention of a foreign body,” and it even has its own acronym, URFO.

The Joint Commission is the American healthcare accreditation organization. In December 2019, it said that in the first six months of 2019 there were 60 reported events of unintended retention of a foreign body.

In 2013, Glenford Turner had prostate surgery at a Veteran Affairs hospital in Connecticut. Afterwards, he suffered from abdominal pain that he endured for four years with doctors being unable to figure out what was wrong. He went for an MRI for a separate condition and that’s when doctors discovered where their missing scalpel was―in Glenford Turner’s pelvis.

His lawyer, Joel Faxon, told National Public Radio, “It’s perplexing to me how they could be so incompetent that a scalpel that really should only be on the exterior of your body not only goes into the body but then is sewn into the body. It's a level of incompetence that’s almost incomprehensible.”

Wrong Patient

In 2018, a patient was wheeled into an operating theatre at the Kenyatta National Hospital, in Nairobi, Kenya. Surgeons began probing for a blood clot in the man’s brain, but they couldn’t find it. That was not surprising really, because they had the wrong patient on the table. Fortunately, the man incorrectly operated on and the man with the blood clot survived. The reputation of the hospital has not.

You might think that this happened in a developing country and would never happen here. You would be wrong to think that.

Albert Hubbard Jr., a 65-year-old from Worcester, Massachusetts had a perfectly healthy kidney removed. The urologist who performed the operation at the St. Vincent Hospital mistakenly read “the CT scan of another man with the same name” (Telegram and Gazette).

Wrong Medication

Matthew Grissinger is the Director of Error Reporting Programs at the Institute for Safe Medication Practices in Horsham, Pennsylvania. He wrote of a mix-up in an emergency room.

A traffic accident victim and dehydrated cancer patient were admitted at the same time and attended by the same physician. The doctor prescribed a muscle relaxant (vecuronium) and a sedative (midazolam) for the accident case prior to intubation. However, he electronically entered this information on the cancer patient’s chart. A change of nursing shift resulted in the wrong medication being given to the cancer sufferer who went into respiratory failure and died.

Nurses are routinely pressed into working long shifts and even double shifts. The Canadian Nurses Association notes that this leads to exhaustion, “creating an unrelenting overall condition that interferes with individuals’ physical and cognitive ability to function to their normal capacity.” That’s when treatment mistakes happen. Nurses working for more than 12.5 hours “are likely to make three times more errors.”

So, patients get a medication meant for someone else, or the get the wrong dosage, or some other kind of mistake happens.

Reducing Never Events

All health care facilities work hard at ensuring never events don’t happen, but still they do. Why?

It’s almost always down to the human factor; people are fallible, they make mistakes. They don’t mean to, but they get distracted, they get tired, they have other life events that pre-occupy their minds.

That’s why extensive protocols are put in place so that steps in a patient’s treatment are carefully logged and checked, and re-checked. Yet still, the gremlins creep in.

Sometimes, it can be blamed on incompetence. It’s as well to remember that fifty percent of the medical professionals practicing today graduated in the bottom half of their classes.

Managed Healthcare Executive sums up: “When a marketer makes a typo on a press release, the worst case scenario is typically a minor loss of credibility. If a healthcare practitioner were to make the same mistake on a patient’s chart, say by accidentally prescribing clozapine instead of olanzapine (two ‘look-alike, sound-alike’ drugs, which are often confused), the result could be catastrophic.”

Bonus Factoids

  • The U.S. Food and Drug Administration says it “receives more than 100,000 U.S. reports each year associated with a suspected medication error.”
  • The Centers for Disease Control estimates that 250,000 American die each year because of medical mistakes.
  • Iatrogenesis is a word that comes from ancient Greek and it means “brought forth by a healer.” It describes maladies that result from contact within the health care system, such as catching an infection while in a hospital. A study published in the European Journal of Internal Medicine found that among 879 patients in a hospital’s ward “A total of 102 patients (22.9%) developed 121 iatrogenic events.” Of these, three died from their iatrogenic illnesses.

Sources

  • “13 Statistics on Never Events.” Megan Knowles, Becker’s Healthcare, July 3rd, 2018.
  • “Incidence of Wrong-Site Surgery List Errors for a 2-Year Period in a Single National Health Service Board.” Alistair Geraghty et al, Journal of Patient Safety, March 2020.
  • “Former Yale Surgeon Fights to Clear his Name.” Amy Xiong and Madison Mahoney, Yale News, August 13, 2018.
  • “Retained Foreign Bodies and Wrong Site Surgery Continue to Be a Challenge.” Carlos A. Pellegrini MD et al, Bulletin of the American College of Surgeons, December 4, 2019.
  • “Veteran Sues After Scalpel Found Inside His Body 4 Years After Surgery.” Merritt Kennedy, National Public Radio, January 16, 2018.
  • “Oops, Sorry, Wrong Patient!” Matthew Grissinger, RPh, FASCP, U.S. National Library of Medicine, August 2014.
  • “Nurse Fatigue.” Canadian Nurses Association, August 2012.
  • “Kenya Doctors ‘Perform Brain Surgery on Wrong Patient.’ ” BBC News, March 2, 2018.
  • “Massachusetts Surgeon Reprimanded for Removing Kidney from Wrong Patient.” Brad Petrishen, Telegram & Gazette (Worcester), January 23, 2019.
  • “Working to Reduce Medication Errors.” FDA, August 23, 2019.
  • “Four Ways to Reduce Dangerous Medical Errors at your Hospital.” Kenneth Maxik, Managed Healthcare Executive, January 17, 2017.
  • “The Diseases we Cause: Iatrogenic Illness in a Department of Internal Medicine.” Sofia Madeira et al, European Journal of Internal Medicine, September 2007.

This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

© 2020 Rupert Taylor

Comments

Rupert Taylor (author) from Waterloo, Ontario, Canada on December 13, 2020:

Glad your experience was a good one DW as the vast majority of cases are. The protocols worked for you and they didn't try to perform a hysterectomy. But, in the age of Covid all bets are off; I don't know how they can manage.

DW Davis from Eastern NC on December 13, 2020:

Thank you for the great Hub. People should be pro-active when they go into the hospital and ask as many questions as they feel are necessary to give them confidence the right things will be done.

The hospital where I had my hip replacement done had several layers of confirmation between admission and the OR to ensure the correct hip was operated on. These measures included asking me several times who I was, my birth date, why I was there, who my surgeon was, which hip was being replaced. I also wore a bar code bracelet that identified me to the computer.

This was a few years pre-COVID. I cannot imagine the mistakes that might be made today with hospital workers under the stress and fatigue they're suffering.

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