Surgical never events: How to stop these preventable medical errors once and for all

As a longtime healthcare reporter, I am shocked every time I read about a surgeon who operated on the wrong site or wrong patient or accidentally left a surgical instrument inside a patient's body. It seems hard to believe that in 2015 these "never events" could occur at all. Yet they do, and, if recent studies are correct, they occur far too often.

One way to solve this problem in the operating room once and for all is to eliminate distractions and adopt best practices followed by the aviation industry--basically turning the operating room into a cockpit, Kimberly Danebrock, R.N., senior risk management and patient safety specialist for the Cooperative of American Physicians' "CAPAssurance" program, told me during an exclusive interview. 

We spoke shortly before the release this week of a study conducted by researchers at the Mayo Clinic that found never events occurred at their campus during 1 of every 22,000 procedures. But the national rate for never events is much higher. A 2013 study published in Surgery estimated it to be closer to 1 in 12,000 procedures.

And JAMA Surgery published another study this week that took a systematic review of surgical never events, including wrong-site surgery, retained surgical items and surgical fires, to try to determine why they still happen despite the implementation of patient safety efforts at hospitals across the country.

The study found that poor communication is behind most of these catastrophic events, a problem also identified by Mayo Clinic researchers. The Mayo study also identified a series of as many as nine missteps that can lead to a surgical error.

CAP's Danebrock, pictured right, often tells physicians that the latest research shows that medical errors contribute to the deaths of 210,000 to 400,000 patients a year, far more than the 44,000-98,000 figure cited in the Institute of Medicine's landmark 1999 report, To Err is Human: Building a Safer Health System.

That figure becomes all too real to doctors when she suggests they take the 98,000 IOM estimate and divide it by 365 days a year. The result: 268 patients a day. What if all those people were on airplanes that crashed, every single day? How many of us would fly?

"When they think about the number of jet liners that would have to crash it always grabs their attention," Danebrock says. 

To prevent these errors, Danebrock says hospitals must change their patient safety culture throughout their organizations, not just in the OR. This culture must encourage all workers to speak up when they spot a potential safety problem.

"Any time you change the culture in an institution it has to come from the top," she says. "We need to educate the hospital administration and physicians on what they need to do and why they need to do it.

"Physicians often don't feel comfortable sharing mistakes for fear of shame or loss of reputation. But if this starts with the top--if physicians feel comfortable talking about near-misses and their peers have an open, transparent relationship--then I think that would go down to nurses and technicians. And hospitals can work with each of these groups and talk about the importance of patient safety and [that] it's okay to talk about mistakes." .

Danebrock noted that the Joint Commission also identified poor communication among healthcare workers as a barrier to patient safety and the root cause of medical errors. The accreditor's Universal Protocol requires the surgical team to take a "time out" prior to a surgery to ensure that they are about to perform the correct procedure on the correct patient and on the correct site.

But if a surgeon is under pressure to quickly get the surgery done in order to get the operating room ready for the next patient, he or she may not always follow the time-out protocol.

"If the surgeon or if a nurse is not wholeheartedly invested, you can see where there is potential for error," she says.

Danebrock says hospitals can prevent surgical errors by following three steps:

Standardize the "call for quiet:" Implement a phrase that all staff will use during the critical times of starting and ending a procedure. A phrase such as "safety silence," for example, will remind all physicians and staff to stop all non-essential activity and conversation to create an environment that is entirely patient-centered.

De-ice the OR: Create an atmosphere of psychological safety and teamwork, she says. Don't tolerate intimidating behaviors that cause tension and may stop someone from bringing up a safety concern. Before starting the case, the team leader should ask each team member to introduce themselves and invite anyone to escalate a patient safety concern at any time during the procedure.

Tune up the time-out:  Joint Commission researchers cited team inattention during the time-out as a predominant risk for wrong site surgery. To improve team attention, Danebrock says organizations should structure the time-out checklist as a series of questions, so that team members must evaluate information before responding. To increase engagement, she suggests the team leader assign each team member to a brief but specific task.

When the entire team is engaged, the chances of catching an error increase greatly, she says.

For the sake of your patients, your staff and your team, it's well worth the time. --Ilene (@FierceHealth)