Surgery ‘never events’ happen every week in US

JOHNS HOPKINS (US) — Surgeons in the US leave a foreign object such as a sponge or a towel inside a patient’s body 39 times a week, perform the wrong procedure 20 times a week, and operate on the wrong body site 20 times a week.

Published online in the journal Surgery, the analysis of malpractice claims estimates that 80,000 of these so-called “never events” occurred in American hospitals between 1990 and 2010. The estimate is likely on the low side, they say.

The findings—believed to be the first of their kind—quantify the national rate of surgical occurrences that professionals universally agree should never happen. Documenting the magnitude of the problem, the researchers say, is an important step in developing better systems to ensure never events live up to their name.


“There are mistakes in health care that are not preventable. Infection rates will likely never get down to zero even if everyone does everything right, for example,” says study leader Marty Makary, associate professor of surgery at Johns Hopkins University School of Medicine.

“But the events we’ve estimated are totally preventable. This study highlights that we are nowhere near where we should be, and there’s a lot of work to be done.”

Makary and his colleagues conducted their analysis with information from the National Practitioner Data Bank, a federal repository of medical malpractice claims. They identified malpractice judgments and out-of-court settlements related to retained-foreign-body incidents (leaving a sponge or other object inside a patient), and to wrong-site, wrong-procedure and wrong-patient surgeries.

They identified 9,744 paid malpractice judgments and claims over those 20 years, with payments totaling $1.3 billion. Death occurred in 6.6 percent of patients, permanent injury in 32.9 percent and temporary injury in 59.2 percent.

Using published rates of surgical adverse events resulting in a malpractice claim, the researchers estimate that 4,044 surgical never events occur in the United States each year.

The NPDB is the best source of information about malpractice claims for never events because these are not the sort of claims for which frivolous lawsuits are filed or settlements made to avoid jury trials. By law, hospitals are required to report never events that result in a settlement or judgment to the NPDB.

“There’s good reason to believe these were all legitimate claims,” he says. “A claim of a sponge left behind, for example, can be proven by taking an X-ray.”

If anything, he says, his team’s estimates of never events are low because not all items left behind after surgery are discovered. Typically, they are found only when a patient experiences a complication after surgery and efforts are made to find out why, Makary says.

At many medical centers, Makary says, patient safety procedures have long been in place to prevent never events, including mandatory “timeouts” before operations begin to make sure medical records and surgical plans match the patient on the table.

Other steps include using indelible ink to mark the site of the surgery before the patient goes under anesthesia. Procedures have long been in place to count sponges, towels, and other surgical items before and after surgery, but these efforts are not foolproof, Makary notes. Many hospitals are moving toward electronic bar codes on instruments and materials to enable precise counts and prevent human error. Surgical checklists are also often in place.

Along with better procedures to prevent never events, better reporting systems are needed, Makary says. He advocates public reporting of never events, an action that would give consumers the information to make more informed choices about where to undergo surgery, as well as “put hospitals under the gun to make things safer.”

Currently, hospitals are supposed to voluntarily share never event information with the Joint Commission, which assesses hospital safety and practice standards, but that doesn’t always happen.

Source: Johns Hopkins University