Surgical “Never” Events Occurring 80 Times a Week

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According to a detailed review of data from 1990-2010 located at the National Practitioner Data Bank, the federal repository of medical liability claims, surgical errors that are considered “never” events happen about 80 times a week. The findings were published in the December 2012 issue of Surgery. Such “never” events include sponges unintentionally left behind in the patient, wrong site surgeries, and wrong patient surgeries. According to American Medical News, “Researchers found nearly 10,000 cases of these so-called never events totaling $1.3 billion in settlements. Based on previous studies finding that about 90% of injured patients do not receive indemnity payments and so would not be included in the data bank, the researchers calculated an annual rate of 4,082 surgical never events, or 78.5 each week. Given the common estimate that 50 million operations are done each year in the U.S., the calculation would translate to one surgical never event in every 12,248 procedures. Although surgical never events are extremely rare, that does not lessen the gravity of these mistakes, said T. Forcht Dagi, MD, MPH, chair of the American College of Surgeons’ Committee on Perioperative Care.” While this problem is chronic, the solution remains elusive. Checklists, improved communication procedures, and training have failed to stem this disturbing tide.

Holly Haines
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