Study: Communication issues are often behind surgical ‘never events’

Recent research attributes many preventable “never events” to ineffective communication between surgical staff members.

"Never events" are outrageous surgical errors, such as wrong-site operations, that should never excusably occur. According to The Wall Street Journal, in 2012, a John Hopkins University School of Medicine study found that these events happen at least 4,000 times annually. Sadly, these mistakes often have tragic outcomes for patients in New York City. According to the same study, about one-third of these errors cause serious permanent injuries, and about one out of 20 result in death.

Unlike some surgical errors, never events are fully preventable. To reduce the risk of these mistakes occurring, hospitals have implemented strict surgical procedures and checklists. However, research suggests that communication issues among surgical staff may still cause a substantial number of errors.

Harmful misunderstandings

According to Fox News, a recent study reviewed 138 other studies that were published over the last decade. These studies all focused on retained-object errors, surgical fires or wrong-site procedures. The researchers found that the factors underlying each error were typically complex, and overall error rates varied between procedures. However, the following communication-related variables were common factors in never events:

  • Operating room staff failing to receive available information
  • Poor communication or misunderstandings between staff members
  • Surgical staff members failing to share their concerns
  • Surgical staff members dismissing the concerns of other staff members

The researchers could not identify a simple approach to prevent never events, given the complex factors that often contribute to these events. However, the researchers suggested that doctors and hospitals focus on more effectively tracking actual errors and close calls. This could allow doctors to identify common mistakes and develop approaches to prevent them from happening again.

Life-changing errors

The study concluded that surgical errors are relatively rare events. Doctors leave behind objects, such as surgical sponges or equipment, during about one procedure out of every 10,000 procedures. Wrong-site surgeries occur about 1 in 100,000 times. Still, these rates of medical negligence are far too high, considering the serious nature of these errors.

According to The Wall Street Journal, never events often cause patients harm. More than half of these events result in some form of injury, and infection can also be a risk. Some errors are not even discovered until complications develop, which leaves patients in danger of more serious outcomes.

Potential remedies

People who suffer injuries because of needless medical mistakes may have legal recourse. However, in New York, injury victims typically only have 30 months after the date that an error occurs to file a claim. In some cases, victims may not even discover errors until much of this time has passed. This makes promptly consulting with a medical malpractice attorney advisable for anyone who has suffered harm because of substandard medical care.

Keywords: never events, malpractice, negligence, doctor, hospital