Making Sure 'Never Events' Never Happen Again During Surgeries

While serious surgical errors – so-called “never events” such as operating on the wrong body part or wrong patient or leaving a surgical instrument inside a patient – are rare, they still continue to happen in the nation’s hospitals. A number of groups have stepped up efforts to prevent never events in a quest to make the occurrences live up to their nickname.

A recent article from Fierce Healthcare outlines the Cooperative of American Physicians’ (CAP) CAPAssurance program, which encourages the elimination of operating room distractions and the adoption of best practices similar to those used in aviation.

Kimberly Danebrock, R.N., senior risk management and patient safety specialist for CAP, often tells doctors that research shows medical errors contribute to between 210,000 and 400,000 patient deaths each year, according to the article. She said hospitals must change their entire patient safety culture to prevent these errors – a cultural change that will encourage all hospital workers to speak up about potential patient dangers.

The article also reported on a Mayo Clinic study that found never events occurred at its clinic during 1 in 22,000 procedures, although the national rate is much higher. Fierce Healthcare cited a 2013 study that estimated never events occur during nearly 1 in 12,000 procedures.

The Mayo Clinic study and a study published in JAMA Surgery both looked at why never events continue to happen even while patient safety efforts have increased in hospitals across the country. Both studies found poor communication is a factor that can lead to such surgical errors. The Mayo Clinic study focused on human factors and how they contribute to never events.

Memorial Healthcare System, based in Hollywood, Fla., was able to improve patient safety, especially in its operating rooms, through new safety protocols, which include checklists, huddles, briefings, and debriefings for surgeries, as well as communication scripts, Fierce Healthcare reports.

CAP’s Danebrock said in the Fierce Healthcare article that hospitals must change their entire patient safety culture to prevent these errors, fostering an environment that will encourage all hospital workers to speak up about potential patient dangers.

“Any time you change the culture in an institution it has to come from the top,” she said. “We need to educate the hospital administration and physicians on what they need to do and why they need to do it.”

Danebrock identified these three steps to prevent surgical errors:

1. Standardize the “call for quiet.“ This involves implementing a phrase all staff will use during the crucial beginning and ending of a procedure. The phrase should remind all staff to focus on the patient rather than other activities.
2. De-ice the OR. Hospitals need to create an atmosphere that focuses on teamwork and psychological safety, according to Danebrock. This means not tolerating behaviors that would discourage someone from speaking up about a safety concern. All team members should introduce themselves before every procedure and the team leader should invite members to bring up patient safety concerns.
3. Tune up the time-out. Failure to pay proper attention is a key risk for wrong-site surgery. To improve staff attention, Danebrock recommends structuring the time-out checklist as a series of questions, which makes sure team members evaluate the information before responding.

The attorneys of Morrow Kidman Tinker Macey-Cushman, PLLC represent patients who have been harmed by preventable medical errors in Seattle and across Washington. Schedule a free consultation by calling us or contacting us online.