“Never” Events Actually Happen about 80 Times per Week

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By, Katie Leander

Ah, the irony. “Never events” – events so unacceptable that they should never happen – have been found to happen about 80 times per week across the U.S. , according to a new study. What are some examples of “never” events? They include: operating on the wrong patient, operating on the wrong body part, performing the wrong procedure, or leaving an instrument inside a patient. These are major errors, despite a 2004 Joint Commission mandate of a 3-step universal protocol, to prevent wrong-site and wrong-patient surgeries, that every operating room should have in place to avoid them. But, I guess protocols and checklists can’t follow and check themselves.

The study, published in the Dec. 17, 2012 issue of Surgery, reviewed settlement and judgment data from the National Practitioner Data Bank over a period of 20 years, 1990-2010. Ten thousand never events were found with awards that totaled about $1.3 billion. The researchers used additional data, calculating for the fact that 90% of injured patients don’t receive a payment, to calculate the average of about 80 never events per week.

While this number seems high, when compared to the number of surgeries performed in a given year, this averages only about 1 in 12,248 surgeries. However, given the extreme nature of these events, even one is too many. This is especially true, considering about one-third of the cases resulted in permanent injury.
It should be noted that this data also dispelled some assumptions that some might be inclined to make. The errors did not occur more frequently among younger, less experienced physicians, or older physicians, as one might expect. It seems that errors like this can cause anyone to have to use their medical malpractice insurance. The never event errors occurred fairly evenly among all age groups.

Katie Leander is a writer with