Challenges in Reducing Surgical “Never Events”

Abstract

Theoperating room is a complex, high-risk systemwhere adverse events remain commonplace. Certain errors, including wrong-site surgery,a retainedsurgical item(RSI),oranoperating roomfire,have been termed never events, indicating these should be 100% preventable.Despite significantattentionandpreventionefforts,never events still occur. It is estimated that physicians operating on bilateral structures will have a 25% lifetime risk of performing wrongsite surgery and that 1 in 8000 inpatient operations will have an RSI.1,2 These events can lead to significant physical andpsychological harm to patients. The consequences can also be severe for cliniciansand institutions, including theprofoundpsychological toll on involvedclinicians, aswell as the financial burdenofmedicolegal action and negative effects on professional reputation.3 In a study published in JAMA Surgery, Hempel et al4 conducted a systematic review to examine the current body of literature for the incidence, root causes, and interventions to prevent wrong-site surgery, RSIs, and surgical fires after the implementation of the Joint Commission’s Universal Protocol in 2004. Based on their assessment of 138 empirical studies, the authors concluded that the incidence andestimates forwrong-site surgery and RSIs are low (median estimate of 0.09 events per 10 000 surgical procedures and 1.32 events per 10 000 procedures, respectively) and vary considerably by data source and procedure. In addition, therewerenodata to estimate the frequencyof surgical fires. Even though the authors identified that studies highlighted the need for better communicationas amajor contributing factor to thesenever events, of more concern is that no clear mechanism has been developed toprevent or considerably reduce themiscommunication. The evidence supporting the effectiveness of the few existing interventions to reduce these events is inconclusive. Reducing the incidence of these serious events requires amultifaceted approach. In light of the study’s findings, several targets JAMASURGERY