A recent LinkedIn share by Doug Beighle, President COO of Simulab and Mercy written by the Mayo Clinic on how “More Than 600 Factors Contribute to Never Events” hosted by SurgicalProductsMag.com.
Why are major surgical errors called “never events?” Because they shouldn’t happen — but do. Mayo Clinic researchers identified 69 never events among 1.5 million invasive procedures performed over five years and detailed why each occurred. Using a system created to investigate military plane crashes, they coded the human behaviors involved to identify any environmental, organizational, job and individual characteristics that led to the never events. Their discovery: 628 human factors contributed to the errors overall, roughly four to nine per event. The study results are published in the journal Surgery.
The never events included performing the wrong procedure (24), performing surgery on the wrong site or wrong side of the body (22), putting in the wrong implant (5), or leaving an object in the patient (18). All of the errors analyzed occurred at Mayo; none were fatal.
The Mayo Rochester campus rate of never events over the period studied was roughly 1 in every 22,000 procedures. Because of inconsistencies in definitions and reporting requirements, it is hard to find accurate comparison data, but a recent study based upon information in the National Practitioner Data Bank estimated that the rate of such never events in the United States is almost twice that in this report, approximately 1 in 12,000 procedures.
Nearly two-thirds of the Mayo never events occurred during relatively minor procedures such as anesthetic blocks, line placements, interventional radiology procedures, endoscopy and other skin and soft tissue procedures.
Medical teams are highly skilled and motivated, yet preventing never events entirely remains elusive, says senior author Juliane Bingener, M.D., a gastroenterologic surgeon at Mayo Clinic. The finding that factors beyond “cowboy-type” behavior were to blame points to the complexity of preventing never events, she says.
“What it tells you is that multiple things have to happen for an error to happen,” Dr. Bingener says. “We need to make sure that the team is vigilant and knows that it is not only OK but is critical that team members alert each other to potential problems. Speaking up and taking advantage of all the team’s capacity to prevent errors is very important, and adding systems approaches as well.
To investigate the never events, the researchers used human factors analysis, a system first developed to investigate military aviation accidents.”
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