When "I've Got Two Left Feet" is All Too Real

“Never events” were in the news recently when a man was given two right knees in a knee replacement on the wrong leg. It turned out the same hospital is under investigation for a retained vaginal swab that caused “moderate harm,” according to the article, just a couple months before. The hospital at issue serves parts of London.

A surgeon performs surgery on a patient’s leg . . . but the wrong leg. A surgeon leaves something—a tool, and sponge, a towel—inside the patient’s body by mistake. These types of shocking errors should simply never happen. But they do happen. Frequently enough that the Centers for Medicare and Medicaid services, the governmental agency picking up the bill for some of these preventable errors, calls them “never events.” And it told hospitals it would stop paying that bill back in 2008.

The term “never events” was coined by Dr. Ken Kizer, former CEO of the National Quality Forum (NQF), to refer to clinically devastating and preventable adverse events. Patient Safety Network defines never events as, “a particularly shocking medical error that should never occur.” Never events include wrong site surgery, wrong procedure, wrong implant, or retained objects in a patient.

A recent study using information from the National Practitioner Data Bank approximates that 1 in every 12,000 procedures conducted here in the United States results in a never case (Mayo Clinic News Network, 2015).

For an error like this to occur, multiple things have to take place. Distractions, overconfidence, stress, mental fatigue, disorganization, and inadequate communication can all play a factor in this type of mistake. Juliane Bingener, M.D., a gastroenterologic surgeon at Mayo Clinic, insists that in an effort to prevent such mishaps from occurring medical professionals need to alert each other of potential problems as they occur (Mayo Clinic News Network, 2015).

As an example, the Mayo Clinic installed a sponge-counting system and now utilizes a bar code-scanning system in an effort to track the sponges used by their surgical team and prevent such sponges from being left in patients.

The key is that these are preventable errors: not just a bad outcome, but a bad outcome that should not happen if people were reasonably careful. I’ve worked on cases involving the wrong medicine being given to a patient—which can render them brain-damaged, or dead—and patient falls are all too common. Some states mandate these events be reported.

As clear as these cases seem to be, I’m still called by families with a loved one harmed by a never event, and the facility wants to fight over whether to compensate them for what the facility did wrong. We should all be working to make sure that they get justice and, even better, the facility implements programs to make sure it never happens again. “Never Events” should be just that.


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