Never Events in Surgery

Never events encompass a variety of mishaps that are egregious, preventable, and unfortunately too common for modern health care systems. Surgeons are most familiar with wrong-site, wrong-person, and wrong-procedure surgery and with retained foreign bodies. In broader terms, never events may also include repercussions of ABO incompatible transfusion, air embolism, discharge of an infant to the wrong person, abduction, inpatient suicide, and sexual assault at a health care facility. Some organizations include health care–associated conditions (such as infections), in-facility burns, and bedrail injuries. Although physicians often subscribe to the Hippocrates concept of primum non nocere (first do no harm), the modern intricacy of health care delivery requires that there be systems in place to help physiciansmeet the Hippocrates mission. Broad cultural and organizational mindfulness regarding strong prevention measures are a cornerstone for safety and the avoidance of never events. On an international basis, never events are defined and processed in different manners. In the UK, the National Health Service (NHS) uses a structured reporting system with quarterly communications. In the USA, the Center for Medicare Services, the National Quality Forum, and the Joint Commission [1] have different reporting standards and heterogeneous classifications for these serious events. Hence, comparison of never events across the world may be challenging if not impossible. Despite these challenges, there are universal recommendations to aid in prevention, including evidence-based system improvements, checklists, mindful protocols, and the minimization of human variation in the approach to patient care. On a local and financial level, the occurrence of surgical never events may have potentially serious consequences on a surgeon’s career and an organization’s reputation. The everlasting impact to a surgeon may not only be professional, but also psychological. The organization can be injured in both prestige and pocketbook. Medical insurance companies are increasingly focusing on these never events as surrogate marker for poor quality health service, and insurers in the USA now do not reimburse for surgical never events. Additionally, they have adopted policies of penalizing hospitals for poor quality, in which serious adverse events play a role [2]. A review of National Practitioner Data Bank in the USA over the period of 20 yr ending 2010 identified 9744 paid malpractice claims involving surgical never events. The most common type of event was a retained foreign body (49.8%), followed by wrong-procedure (25.1%), wrong-site (24.8%), and wrong-patient surgery (0.3%). The aggregate malpractice payments amounted to over US$1.3 billion. In addition, 6.6% of these surgical never events resulted in the death of the patient. Other adverse patient effects included permanent injury (32.9%), temporary injury (59.2%), and emotional injury (1.3%) [2]. Similarly, the NHS provisional publication of never events published in March 2015 identified 271 events between April 2014 and February 2015. Wrong-site surgery accounted for 42% and retained foreign objects for 41.7% [3]. Urologists may be surprised to learn that our field accounts for 20% of wrong-site surgeries [4]. The paired urological organs and the concealed location of kidneys and ureters within deep body compartments escalate the risk of wrong-site surgery in urology. Computed tomography scans, intravenous pyelograms, and other imaging tests can be misinterpreted with subsequent improper identification. Mistakes such as covering the site with drapes and not using a radiopaque marker for fluoroscopy cases [4] contribute to these events in the urologic domain. Local examination of these behaviors can minimize such faults. On a broader scale, prevention is the best approach for averting surgical never events in all facilities around the world. Prevention relies on several robust processes. E U RO P E AN URO L OG Y 6 8 ( 2 0 1 5 ) 9 1 9 – 9 2 0