Healthcare News & Insights

Avoid ‘never events’ in surgery: 4 areas to watch

New research provides insight into why many surgical “never events” occur – which should arm hospitals with the information they need to prevent them. 

200252902-001The Mayo Clinic performed an analysis of thousands of never events in hospitals, including performing the wrong surgery, performing surgery on the wrong site or side of the body, and leaving an object in the patient after a procedure.

According to a news release about the analysis, most of the never events examined by the researchers occurred during relatively minor procedures and surgeries, including line placements and endoscopies.

Types of issues

From its analysis, the clinic found dozens of what it called “human factors” that contributed to the errors. These human factors can all be classified into four categories:

  1. Preconditions for action. This refers to outside factors that affect the outcome of the procedure. These can be directly related to the success of the procedure, such as an incomplete hand-off conversation. Or they can be factors totally unrelated to the surgery, like a surgeon’s level of stress or mental fatigue. Having too much of a singular focus on one issue or aspect of the surgery (or, more simply, failing to see the forest for the trees), can also have a negative effect on this area.
  2. Unsafe actions. Here, surgeons or other hospital staff may take unsafe shortcuts, or bend or break the rules entirely, directly putting the patient in danger. Indirect unsafe actions also fall under this category – including the issue of confirmation bias, where surgeons and other staff were convinced their course of action was safe when, upon closer examination, it wasn’t.
  3. Oversight and supervisory factors. This one is pretty straightforward. Surgical staffers weren’t supervised properly during the procedure, either due to staffing issues, planning problems or other unanticipated concerns.
  4. Organizational influences. Surgical staff who made errors that caused never events often worked in hospitals with a culture of secrecy surrounding errors, or with a culture that didn’t support best practices for safe surgery. This included issues with standardizing processes involved with operations and procedures.

Prevention strategy

The key element that can dull the effect of many of these human factors: communication. Improving communication between surgical staff, patients and healthcare executives may keep many of these factors from causing dire consequences in surgery.

Having quick surgical team “huddles” and debriefings before surgery can help prevent many errors. During the debriefing, staff can quickly run down the checklist for the Joint Commission’s Universal Protocol for surgery. This can help remind staff of the important steps they should take to avoid issues during the procedure.

And regular meetings about the outcomes of surgery, where staff can share any issues or errors with the top brass in an environment where they won’t be punished or judged, are also helpful in preventing never events from harming patients.

A hospital with a culture that prioritizes open communication and learning from mistakes over secrecy and punishment will likely have more error-free surgeries in the long run.

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