“Never Mistakes” During Surgery

Human error is a natural part of any medical care in New Mexico. Not all errors can be avoided, but even within the medical community, there are mistakes that are not tolerated. These “never mistakes” are things that should never happen. Pacific Standard notes that “never mistakes” are rare, but that every year around 5,000 people end up having an object left inside their bodies during surgery, and when it comes to operating on the wrong body part, about 500 people experience that each year. None of these things should ever happen, and prevention can help to stop them.

The Agency for Healthcare Research and Quality notes there are protocols to avoid “never mistakes”, or “never events” as the agency refers to them.  Included in the protocols is the requirement for a time-out before beginning an operation. This pause is taken to allow a review of all the information and the patient to ensure no mistake is made as to what procedure is being done, where it is being done and to whom it is being done. Another protocol is to mark the surgical site in some way. However, there have been issues with this causing confusion between whether the marked site is the site to be operated on or not to be operated on.

Communication seems to be the key to preventing “never events.” Ensuring that all members of the surgical team understand the details about the procedure and the patient can help to reduce mistakes. In addition, taking the time to go over details and not rushing to get a patient into surgery can also reduce issues.  

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