Surgical “never events”—or occurrences that should never happen, such as operations on the wrong part of the body, or foreign objects left in the body after surgery – are happening at least 4,000 times per year, according to a new study.
The study, conducted by Martin Makary, MD, MPH, and colleagues at Johns Hopkins University in Baltimore, revealed some shocking results. The investigators estimate that surgeons in the United States leave a foreign object (for example, a sponge or towel) inside a patient’s body after an operation 39 times a week. In addition, the study found that surgeons perform the wrong procedure on a patient 20 times a week, and operate on the wrong part of the body 20 times a week.
For the study, researchers looked at records in the National Practitioner Data Bank (NPDB), a national repository of medical malpractice claims. The researchers examined judgments and settlements related to foreign objects left in patients after surgery, wrong site, wrong patient, and wrong procedure surgeries.
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By law, hospitals are required to report to the NPDB all never events that lead to a settlement or judgment, but researchers believe that the number may appear lower than they really are because not all items left behind in surgery are discovered. The researchers looked at data from 1990 to 2010, and estimate that a total of 80,000 never events, and possibly more, took place.
While Dr. Makary’s team noted that patient safety procedures are in place in many medical centers—such as counting sponges and towels before and after surgery, marking the surgery site with indelible ink before the procedure, and making sure that surgery plans and medical records match the patient—these efforts are not foolproof. Some hospitals are moving towards electronic bar codes on materials and instruments to prevent error.
“There are mistakes in health care that are not preventable,” Dr. Makary, Associate Professor of Surgery, said in a news release. “Infection rates will likely never get down to zero even if everyone does everything right, for example. But the events we’ve estimated are totally preventable. This study highlights that we are nowhere near where we should be and there’s a lot of work to be done.”
