Never Events Continue, Despite Universal Protocol

For many people in New Mexico, the thought of undergoing even the most minor surgery is cause for concern. The idea that a medical error could have catastrophic results due to wrong site surgery can be terrifying. The National Center for Biotechnology Information, U.S. National Library of Medicine reports that never events such as wrong-site errors are rare when compared to other preventable medical errors. However, when they occur, the consequences may be disastrous.  

A never event is an adverse event or severe medical error that should never happen. Typically, wrong-site operation occurs when a surgical procedure takes place on the wrong part of the body. This could mean that the surgery is on the left side when it should have been on the right side. It could also be the result of the procedure being on the correct side but an incorrect anatomical part.

The Joint Commission expanded the definition of wrong-site surgery by adding wrong patient surgery and wrong procedure on the right patient. Becker’s Hospital Review reported that more than 4,000 never events happen each year despite the implementation of a universal protocol. Wrong-site, wrong-patient or wrong-procedure incidents were among 2017’s top 10 most frequently reported sentinel events. Getting accurate statistics is difficult as many states do not require that these occurrences are reported. Unfortunately, the most common way to get source data is by finding the number of legal claims.

The majority of never events reported between 1995 and 2015 were fatal. Medical facilities are required to conduct a root-cause analysis following a prespecified protocol after an occurrence. The goal is to identify how and why the error occurred as well as steps needed to prevent it from happening again.

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