PROBLEM: When something goes wrong during a surgery that can be chalked up to human error or a breakdown in the chain of command -- say, a surgical sponge getting left behind in someone's abdomen -- surgeons refer to it as a "never event." Because they should never happen. Unfortunately, they sometimes still do. Measuring how, when, where, and why they happen is a step toward making them literal neverevents.
METHODOLOGY: Johns Hopkins researchers raided a federal trove of official medical malpractice claims to find instances where patients successfully sued -- meaning they needed to have had adequate proof to back up their claims -- over never events that nonetheless occurred. Specifically, they looked at incidents that occurred in the U.S. from 1990 to 2010.
RESULTS: "Never," according to their findings, occurs at least 4,082 times per year. Deaths attributable to these mistakes occurred in 6.6 percent of patients, 32.9 claimed permanent injury, and payments doled out totaled $1.3 billion.
Looked at another way, the researchers estimate that every week, 39 foreign objects are left behind in a patient's body, 20 procedures are performed on the wrong body site, and another 20 are the wrong procedure to begin with. And 12.4 percent of surgeons were repeat offenders.
CONCLUSION: Preventable errors, the researchers conclude, are exacting a serious toll on patients and the health care system.
IMPLICATIONS: Marty Makary, this study's lead author, is a huge proponent of increased transparency in health care; as he told The Atlantic in September, "I think if all of that information is public, patients will not have to walk into a hospital blind. They'll know about the quality of care in their hospital, and the hospital, most importantly, will be accountable." In this case, simple measures that are already used in many medical centers -- like having procedures in place to count sponges and double-triple-quadruple-check patient information before and after surgeries -- can go a long way toward reducing these numbers. In order to drive their widespread implementation in hospitals, Makary argues now, we need to have more data like that revealed in this study to urge them along.
The full study, "Surgical never events in the United States," is published in the journal Surgery .
