There is a certain class of boneheaded mistake that is supposed to be so rare in surgical settings that it’s referred to as a “never event” — as in, this should never happen. The category covers mistakes that are not only grievous, but totally preventable, like leaving equipment inside a patient, performing the wrong surgical procedure, or operating on the wrong body part — or patient — altogether. In news that will no doubt leave anyone going under the knife in the future shuddering, a recent study from Johns Hopkins University found that “never events” happen much more frequently than their name would imply. In fact, it appears that a more fitting title would be “4,000 times a year or so events.”
“Never events” shouldn’t be confused with the understandable complications that can accompany surgeries. As doctors will warn, no surgical procedure is without risk. Cutting someone open and tinkering with their insides is tough, complex work that simply goes wrong sometimes. “Never events,” though, are the sort of surgical problems that should be avoided by dint of simple commons sense — the sort of troubles physicians could avoid altogether by saying things like “Hey, we’re supposed to be working on left knee, aren’t we?” or “Alright, now before we sew up Mr. Jones, everyone make sure they have all of their forceps, because I’m not going back in there.”
The study, published earlier this month in the journal Surgery found that an average of 39 foreign objects are left inside of surgery patients each week in the U.S. If you need that statistic to be more haunting for whatever reason, the study also estimates that many of these objects are sponges, and up to 25% of sponges left inside of patients are never found. Operating on the wrong body part was less common, but still occurred an estimated 20 times per week.
While these findings could be troubling to anyone contemplating a surgical procedure, they should also worry anyone who needs a reasonably priced medical system, and last we checked, that’s all of us. Unforced errors like these drive up the cost of malpractice insurance, and in turn raise the rates each of us pays our doctor for health care, and researchers estimate their costs have run more than a billion dollars in the last twenty years. Which is to say nothing of the cost in pain, suffering and human lives, though, as the report also suggests that one third of the cases it studied resulted in permanent injury, and another 6.6% ended in the patient’s death.
All that means it’s time to step it up a notch, docs. We recognize you’ve got a hard job — we appreciate it and don’t envy it. Next time you’re closing up a patient, though, let’s make sure you’ve got everything out of there — sort of a look twice, sew once policy, you know? Works out better for all parties concerned
(via JD Supra)
- Time to hand surgery over to the video gamers, we guess
- I want gel to replace all my cartilage — when can we start
- Then again, some surgeries go wrong as early as the “idea” stage…
Published: Jan 4, 2013 11:50 am