The term “never events” refers to particularly egregious surgical errors that should never happen to a patient and are entirely preventable. The four main types of never events are:
Wrong site surgeries
Wrong procedures
Wrong patient surgeries
Leaving a foreign object inside a patient
Not only can the occurrence of a surgical never event result in catastrophic injury to the patient, it indicates a lapse in a hospital’s patient safety protocols and culture.
Preventing Never Events
The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery was published by The Joint Commission in 2003 and it has been widely adopted by hospitals across the United States. The protocol is designed to prevent never events through a pre-procedure verification process, marking the correct operative site, and performing a timeout before beginning the surgery.
Despite the widespread implementation of the protocol, surgical never events continue to occur at alarming rates. A 2012 study by Johns Hopkins revealed that around 80,000 never events occurred in American health care facilities between 1990 and 2010. Of the 80,000 never events, 6.6 resulted in death, 32.9 percent resulted in permanent injury, and 59.2 percent resulted in temporary injury.
The study also looked at malpractice claims that arose due to surgical never events and found that payments for these errors totaled $1.3 billion. The researchers from the study reported that they believe their estimates regarding the incidence of surgical never events are likely on the low side.