“Never events” still happen sometimes

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

scalpel
Photo by Garrett P. via Flickr

MedPage Today’s Crystal Phend drew two key lessons from a recent paper on the persistence of “never events,” particularly wrong-patient and wrong-site surgeries, in Colorado.

The first, drawn from an invited critique (subscription required), is that research often underestimates the frequency of never events because, like this study, they rely on self reporting and overly narrow definitions of the events in question. After all, it’s not wise to assume that folks are going to voluntarily link their name to a wrong-patient surgery.

The second is that attempts to prevent never events, such as the Joint Commission-required pre-surgery routine, don’t cast a wide enough net.

Nonsurgical specialists were just as likely to cause significant injury from wrong-site errors as those in the procedural specialties, who have gotten more of the focus (31.2% versus 30.8%, P=0.67).

That’s because, in their analysis, the researchers put the responsibility for wrong procedures at the step where things went wrong, Stahel told MedPage Today. And sometimes that’s before the cutting stage.

“In certain cases we realize that the harm is already done before the patient sets foot in the hospital,” he told MedPage Today.

“Strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to achieve a zero-tolerance philosophy for these preventable incidents,” Stahel’s group wrote.

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