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How Often Do "Never Events" Happen During Surgery?

In the medical profession, never events are occurrences which the entire medical profession agrees should never happen during surgery. But how often do these never events actually happen?

A December 2012 study published in the journal Surgery estimated that 80,000 never events occurred in U.S. hospitals between 1990 and 2010 — that’s 4,000 never events per year. The study believed that its estimates likely were on the low side.

In a first-of-its-kind study, patient safety researchers at Johns Hopkins reviewed national medical malpractice judgments and out-of-court settlements in the National Practitioner Data Bank. During the 20-year period studied, the researchers found 9,744 paid claims and judgments totaling $1.3 billion. The study found that temporary injury occurred 59.2 percent of patients, permanent injury in 32.9 percent and death in 6.6 percent. The study estimated that surgeons make these types of never errors on a weekly basis:

  • Leave a foreign object inside the patient 39 times per week
  • Performs the wrong procedure 20 times per week
  • Operates on the wrong body part 20 times per week

The study revealed that the never events occurred most often in patients ages 40 to 49. Surgeons in that same age group were responsible for more than one-third of the never events. That rate was only 14.4 percent for surgeons over 60.

The researchers hope that determining the magnitude of the never error problem is an important step in developing a system that ensures never errors really never do occur.

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