Malpractice study: Surgical 'never events' occur at least 4,000 times per year

December 19, 2012

After a cautious and rigorous analysis of national malpractice claims, Johns Hopkins patient safety researchers estimate that a surgeon in the United States leaves a foreign object such as a sponge or a towel inside a patient's body after an operation 39 times a week, performs the wrong procedure on a patient 20 times a week and operates on the wrong body site 20 times a week.

The researchers, reporting online in the journal Surgery, say they estimate that 80,000 of these so-called "never events" occurred in American hospitals between 1990 and 2010—and believe their estimates are likely on the low side.

The findings—the first of their kind, it is believed—quantify the national rate of "never events," occurrences for which there is universal professional agreement that they should never happen during surgery. Documenting the magnitude of the problem, the researchers say, is an important step in developing better systems to ensure never events live up to their name.

"There are mistakes in health care that are not preventable. Infection rates will likely never get down to zero even if everyone does everything right, for example," says study leader Marty Makary, M.D., M.P.H., an associate professor of surgery at the Johns Hopkins University School of Medicine. "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."

For the study, Makary and his colleagues used the National Practitioner Data Bank (NPDB), a federal repository of claims, to identify malpractice and out-of-court settlements related to retained-foreign-body (leaving a sponge or other object inside a patient), wrong-site, wrong-procedure and wrong-patient surgeries. They identified 9,744 paid malpractice judgments and claims over those 20 years, with payments totaling $1.3 billion. Death occurred in 6.6 percent of patients, permanent injury in 32.9 percent and temporary injury in 59.2 percent.

Using published rates of surgical adverse events resulting in a malpractice claim, the researchers estimate that 4,044 surgical never events occur in the United States each year. The more serious the outcome, the more the patient (or his family) was paid.

Makary says the NPDB is the best source of information about malpractice claims for never events because these are not the sort of claims for which frivolous lawsuits are filed or settlements made to avoid jury trials. "There's good reason to believe these were all legitimate claims," he says. "A claim of a sponge left behind, for example, can be proven by taking an X-ray."

By law, hospitals are required to report never events that result in a settlement or judgment to the NPDB. If anything, he says, his team's estimates of never events are low because not all items left behind after surgery are discovered. Typically, they are found only when a patient experiences a complication after surgery and efforts are made to find out why, Makary says.

In their study, never events occurred most often among patients between the ages of 40 and 49, and surgeons in this same age group were responsible for more than one-third of the events, compared to 14.4 percent for surgeons over the age of 60. Sixty-two percent of the surgeons were cited in more than one separate malpractice report, and 12.4 percent were named in separate surgical never events.

Makary notes that at many medical centers, procedures have long been in place to prevent never events, including mandatory "timeouts" in the operating room before operations begin to make sure medical records and surgical plans match the patient on the table. Other steps include using indelible ink to mark the site of the surgery before the patient goes under anesthesia. Procedures have long been in place to count , towels and other surgical items before and after surgery, but these efforts are not foolproof, Makary notes. Many hospitals are moving toward electronic bar codes on instruments and materials to enable precise counts and prevent human error. Surgical checklists, pioneered at The Johns Hopkins Hospital, are also often in place.

Along with better procedures to prevent never events, better reporting systems are needed to speed up safety efforts, says Makary.

He advocates public reporting of never events, an action that would give consumers the information to make more informed choices about where to undergo surgery, as well as "put hospitals under the gun to make things safer."

Currently, he notes, hospitals are supposed to voluntarily share never event information with the Joint Commission that assesses hospital safety and practice standards, but that doesn't always happen.

Explore further: Hospitals misleading patients about benefits of robotic surgery, study suggests

Related Stories

Hospitals misleading patients about benefits of robotic surgery, study suggests

May 18, 2011
An estimated four in 10 hospital websites in the United States publicize the use of robotic surgery, with the lion's share touting its clinical superiority despite a lack of scientific evidence that robotic surgery is any ...

Surgical complications twelve times more likely in obese patients

June 30, 2011
(Medical Xpress) -- Obese patients are nearly 12 times more likely to suffer a complication following elective plastic surgery than their normal-weight counterparts, according to new research by Johns Hopkins scientists.

Study points to patient safety risks outside hospital walls

June 14, 2011
Ever since the Institute of Medicine issued its landmark report "To Err Is Human" in 1999, significant attention has been paid to improving patient safety in hospitals nationwide.

For some surgeries, more is better when choosing hospitals

September 1, 2011
Are you scheduled for heart bypass surgery or weight loss surgery? You might want to find out just how frequently different hospitals in your area are performing those procedures before deciding where to go. A new study finds ...

Recommended for you

World's first child hand transplant a 'success'

July 19, 2017
The first child in the world to undergo a double hand transplant is now able to write, feed and dress himself, doctors said Tuesday, declaring the ground-breaking operation a success after 18 months.

Knee surgery—have we been doing it wrong?

July 18, 2017
A team of University at Buffalo medical doctors have published a study that challenges a surgical practice used for decades during arthroscopic knee surgery.

New tools help surgeons find liver tumors, not nick blood vessels

July 17, 2017
The liver is a particularly squishy, slippery organ, prone to shifting both deadly tumors and life-preserving blood vessels by inches between the time they're discovered on a CT scan and when the patient is lying on an operating ...

Researchers discover indicator of lung transplant rejection

July 13, 2017
Research by scientists at Dignity Health St. Joseph's Hospital and Medical Center's Norton Thoracic Institute was published in the July 12, 2017 issue of Science Translational Medicine titled "Zbtb7a induction in alveolar ...

New device could make closing surgical incisions a cinch

July 7, 2017
Like many surgeons, Dr. Jason Spector is often faced with the challenge of securely closing the abdominal wall without injuring the intestines. If the process goes awry, there can be serious consequences for patients, including ...

Success with first 20 patients undergoing minimally invasive pancreatic transplant surgery

June 29, 2017
Surgeons at Johns Hopkins Medicine report that their first series of a minimally invasive procedure to treat chronic pancreas disease, known as severe pancreatitis, resulted in shorter hospital stays, less need for opioids ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.