‘Never Events’ in Surgery Are a Growing Problem

The term ‘never events’ was first coined in 2001 by the National Quality Forum (NQF), an important health organization of USA. The NQF promotes and ensures patient safety and healthcare quality through proper analysis and public reporting.

The NQF defines ‘never events’ as errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients. These indicate a real problem in the safety and credibility of a health care facility. These are called 'never events' because this should never have happened. These include retained foreign body, wrong site surgery, wrong patient surgery, and wrong procedure operations. Never events range from the wrong organ or side being operated on, the wrong prosthesis (such as hip joints) being inserted, to foreign objects (typically surgical instruments and swabs) being left inside the patient.

A 70-year-old man from Alabama recently died at a hospital in Florida when a surgeon mistakenly removed his liver instead of his spleen. The basics of anatomy are the first segment that are taught early in medicine. The liver is situated on the right side and the spleen is located on the left side, which is opposite to the liver. It is difficult to understand how a surgeon might confuse the spleen and liver, which is the foundation of undergraduate medical education. Most surgical careers with super specialty take at least 10 years of medical training to achieve in India, and similar lengths of time in the US and elsewhere. Despite these tedious years of education, the question on existence of never events still persists in the minds of most patients and their family.

Each clinical department have areas where errors are more common than the rest of the field. Studies have tried to analyze and classify these errors over these years as the following:

• Urology : Over 10 percent of cases fail to mention the diseased side (8.7 percent) or they mention the wrong side (3.3 percent).

• Radiology: Wrongly placed radiological films could lead to patients having their healthy kidney removed rather than the diseased one.

• Surgery: There have been cases where women's fertility have been affected because the surgeon removed the wrong fallopian tube or wrong side ovary during surgery.

• Orthopaedics: This is one of the highest rates of wrong-site surgery. 21 percent of hand surgeons confirmed they'd operated on the wrong site.

Sometimes mistaken identities and clerical errors also result in death. Never events have huge implications for patients and their families, and many of them result in significant payouts. The cost of settled claims paid out by the NHS in 2015-20 was over £17 million. And, globally, between 1990 and 2010 claims were over US$1.3 billion (£990 million).

In 2008, the World Health Organization (WHO) launched the surgical safety checklist, which was adopted by the NHS in 2009. Similar protocols have been used in the US since 2004. These sorts of protocols bring consistency in the healthcare system. After the WHO's checklist was introduced, it was shown to reduce post-operative complications and deaths by 36 percent but the never events still have plenty of room for improvement.

WHO's Surgical Safety Checklist is divided into 3 segments as follows for a regular halt before proceeding further into surgery:

• Before induction of anaesthesia

  - Has the patient confirmed his/her identity, site, procedure, and consent?

  - Is the site marked?

  -Is the anaesthesia machine and medication check complete?

  -Is the pulse oximeter on the patient and functioning?

  -Does the patient have a: Known allergy? Difficult airway or aspiration risk?

  -Risk of >500ml blood loss (7ml/kg in children)?

• Before skin incision

  -Confirm all team members have introduced themselves by name and role.

  -Confirm the patient’s name, procedure, and where the incision will be made.

  -Has antibiotic prophylaxis been given within the last 60 minutes?

  -Anticipated Critical Events To Surgeon: What are the critical or non-routine steps? How long will the case take? What is the anticipated blood loss?

  -To Anaesthetist: Are there any patient-specific concerns?

  -To Nursing Team: Has sterility (including indicator results) been confirmed? Are there equipment issues or any concerns? Is essential imaging displayed?

• Before patient leaves operating room

  -Nurse Verbally Confirms: The name of the procedure Completion of instrument, sponge and needle counts

  -Specimen labelling (read specimen labels aloud, including patient name)

  -Whether there are any equipment problems to be addressed

  -To Surgeon, Anaesthetist and Nurse: What are the key concerns for recovery and management of this patient?