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Never Events: Why Do We Tolerate Them? Part 2


Our last post covered the ongoing introspection in the medical profession regarding the persistently high rate of “never events.” These serious surgical errors harm around 4,000 patients every year – even though the name “never” indicates that these mistakes are so preventable that they should not occur at all.

Some organizations are starting to develop new best practices and approaches to eliminating “never event” errors like wrong-site surgeries.

For example, one project has been underway since 2010. This project operates at eight large healthcare organizations. So far, these organizations have been able to dramatically cut the kinds of situations that often lead to never events. These situations, or “process-related problems,” formerly occurred in 52 percent of surgeries – the hospitals cut them down to 19 percent.

This dramatic improvement was possible because the hospitals focused their attention on identifying the kinds of communication mistakes that often result in wrong-site surgeries.

Another project focused on “foreign retained objects” mistakes. The project developed a more sophisticated process for accounting for surgical tools after the procedure – in some cases, with unique bar codes for every single sponge.

Initiatives like these are having big success around the nation. With more encouragement from federal authorities and public interest groups, the medical profession could very likely turn its high rate of big mistakes around – in which case we could actually start thinking of severe errors as “never events.”

Source: MedPage Today, “Zero Tolerance for Medical Error? Think Again!” David Nash, Feb. 27, 2013

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