Fourteen years ago, the Institute of Medicine published a groundbreaking study on medical errors, “To Err is Human”. The findings were startling and sobering. While there have been some improvements since this study was published, “never” events still occur approximately 80 times per week and one estimate of the financial cost of these never events is around $80 billion in the course of twenty years.
Often, “never” events are process related mistakes that can be avoided by a thorough and careful use of medical checklists. According to Dr. David Nash, writing in MedPage, “To its credit, the Joint Commission’s Center for Transforming Healthcare launched a project in 2010 to reduce wrong-site surgery risk at eight healthcare organizations and to provide tools to help others prevent these mistakes.
After these organizations reduced the proportion of cases in which there was a process-related problem that could have resulted in a wrong-site surgery from 52% to 19%, the commission made a wrong-site surgery prevention toolkit available to its accredited hospitals at no cost.
A national surgical safety project — NoThing Left Behind — introduced a slight change in the process for counting sponges at the end of procedures and some organizations have adopted new technologies (e.g., bar-coded sponges) to address the problem of retained foreign bodies.
Despite these and other evidence-based efforts, surgical “never events” continue to occur at the rate of 4,160 every year.”
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