Sentinel and never events in spinal surgery

Abstract

What is a sentinel event? The Joint Commission define it as: “any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient not related to the natural course of a patients illness”.1 Two recent publications look at sentinel events in cervical and lumbar spine surgery from a national database in the USA.1-2 In the UK in the 21st century we talk about ‘never’ events i.e. events that should never occur during the provision of medical care. NHS England2 lists 25 of these, only three are surgical; wrong site surgery, wrong implant/prosthesis and retained foreign object. Application of the World Health Organization surgical safety checklist3 is intended to minimise or abolish the occurrence of such events in the operating theatre. Some of the other never events can apply to surgical patients during their episode of hospital care e.g. maladministration of drugs, issues with nursing care of the elderly and frail, and anaesthetic errors. The issue that challenges surgeons and the legal profession when such events occur (and where it appears that all reasonable precautions have been taken to avoid their occurrence) is whether that sentinel/never event constitutes a breach of the duty of care owed to the patient by the treating surgeon/hospital and if so, what is the effect of that breach. The reviews of Marquez-Lara et al4,5 present a very large cohort of patients reviewed over a long period. In the lumbar spine4 they looked at 543 146 lumbar spine surgeries carried out between 2002 and 2011 from the Nationwide Inpatient Sample (NIS) database. Revision procedures were excluded from the analysis. There were 414 (0.08%) sentinel events. They were: 1. Wrong site surgery: 3 per 10000 cases (0.03%) 2. Vascular injury: …