Study: 4,000 surgical never events occur a year

Malpractice judgments, claims totaled $1.3B
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More than 4,000 surgical "never events" happen every year in the United States, according to a new malpractice study in the journal Surgery, the first quantifiable look at the "totally preventable" mistakes.

Among the findings, a U.S. surgeon leaves a foreign object inside a surgical patient's body 39 times a week and performs wrong-procedure 20 times a week and wrong-site surgery 20 times a week.

Researchers from Johns Hopkins University School of Medicine also found that between 1990 and 2010, 80,000 never events occurred, with 9,744 paid malpractice judgments and claims totaling $1.3 billion. The more serious the outcome, the more money paid to the patient or family, according to the Johns Hopkins research announcement.

The researchers used information from the National Practitioner Data Bank (NPDB), as the law requires hospitals to report never events that result in medical malpractice judgments or out-of-court settlements to the database, The Wall Street Journal reported.

The NPDB has seen the annual rates of reported surgical never events fall, which may stem from hospitals removing physicians from settlement cases, according to the WSJ.

Removing doctors as defendants in malpractice cases allows hospitals to evade the NPDB reporting, a legal maneuver that critics say is unfair protection, FierceHealthcare previously reported.

To ensure patient safety and high-quality care, the industry needs more public reporting of never events to "put hospitals under the gun to make things safer," study leader Marty Makary, an associate professor of surgery at the Johns Hopkins University School of Medicine, said in the announcement.

The study also calls for better procedures to prevent never events, such as mandatory time-outs in the operating room, marking the site of the surgery with permanent ink and using electronic bar codes to keep track of instruments.

Other tips to avoid the never event include staying current on Centers for Medicare & Medicaid Services regulations to ensure 100 percent compliance with minimum standards of care, as well as developing a thorough surveillance plan to monitor areas of potential harm.

For more:
- here's the Hopkins study abstract
- read the research announcement
- check out the WSJ article (subscription required)

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