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80,000 Surgical 'Never Events' Charted Over 20 Years

John Commins, for HealthLeaders Media, December 21, 2012

In addition, 62% of surgeons were cited in more than one malpractice report and 12.4% were named in separate surgical never events. "All doctors have a 62% chance of being sued. Most of them are frivolous lawsuits, so I can't draw much from that," Makary says. "But the 12.4% having previously been involved in a paid settlement for a retained foreign body tells us that we have a high-risk group, and perhaps education efforts or other prevention efforts can be directed toward this high-risk group."

Makary points to protocols such as post-operative checklists and technology that already exists to flag retained sponges. "We have sponges with radio frequency ID tags sewn into the sponge, where a sensor can detect during or after an operation if one of these things is still in the abdomen," he says. "It's technology that makes sense. I've tried it and it works. Hospitals should adopt this technology if they want to get serious about reducing the human factor in this problem."

As troubling as never events are, Makary says they are probably impossible to eliminate because surgeons and other clinicians practice medicine in complex, labor-intensive, high-pressure environments. "For example, the wrong-patient, wrong-procedure confusion will continue to be something that will be a longstanding challenge, even though these events are rare," he says.

Makary believes that increasing transparency in the reporting of never events will motivate hospitals into action. "Some states now have public reporting of never events, like Pennsylvania. It affects hospitals' consumer ratings," he says. "The transparency increases the accountability and the amount of resources a hospital devotes to the problem."


John Commins is a senior editor with HealthLeaders Media.

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