Navigation Links
Johns Hopkins malpractice study: Surgical 'never events' occur at least 4,000 times per year
Date:12/19/2012

After a cautious and rigorous analysis of national malpractice claims, Johns Hopkins patient safety researchers estimate that a surgeon in the United States leaves a foreign object such as a sponge or a towel inside a patient's body after an operation 39 times a week, performs the wrong procedure on a patient 20 times a week and operates on the wrong body site 20 times a week.

The researchers, reporting online in the journal Surgery, say they estimate that 80,000 of these so-called "never events" occurred in American hospitals between 1990 and 2010 and believe their estimates are likely on the low side.

The findings the first of their kind, it is believed quantify the national rate of "never events," occurrences for which there is universal professional agreement that they should never happen during surgery. Documenting the magnitude of the problem, the researchers say, is an important step in developing better systems to ensure never events live up to their name.

"There are mistakes in health care that are not preventable. Infection rates will likely never get down to zero even if everyone does everything right, for example," says study leader Marty Makary, M.D., M.P.H., an associate professor of surgery at the Johns Hopkins University School of Medicine. "But the events we've estimated are totally preventable. This study highlights that we are nowhere near where we should be and there's a lot of work to be done."

For the study, Makary and his colleagues used the National Practitioner Data Bank (NPDB), a federal repository of medical malpractice claims, to identify malpractice judgments and out-of-court settlements related to retained-foreign-body (leaving a sponge or other object inside a patient), wrong-site, wrong-procedure and wrong-patient surgeries. They identified 9,744 paid malpractice judgments and claims over those 20 years, with payments totaling $1.3 billion. Death occurred in 6.6 percent of patients, permanent injury in 32.9 percent and temporary injury in 59.2 percent.

Using published rates of surgical adverse events resulting in a malpractice claim, the researchers estimate that 4,044 surgical never events occur in the United States each year. The more serious the outcome, the more the patient (or his family) was paid.

Makary says the NPDB is the best source of information about malpractice claims for never events because these are not the sort of claims for which frivolous lawsuits are filed or settlements made to avoid jury trials. "There's good reason to believe these were all legitimate claims," he says. "A claim of a sponge left behind, for example, can be proven by taking an X-ray."

By law, hospitals are required to report never events that result in a settlement or judgment to the NPDB. If anything, he says, his team's estimates of never events are low because not all items left behind after surgery are discovered. Typically, they are found only when a patient experiences a complication after surgery and efforts are made to find out why, Makary says.

In their study, never events occurred most often among patients between the ages of 40 and 49, and surgeons in this same age group were responsible for more than one-third of the events, compared to 14.4 percent for surgeons over the age of 60. Sixty-two percent of the surgeons were cited in more than one separate malpractice report, and 12.4 percent were named in separate surgical never events.

Makary notes that at many medical centers, patient safety procedures have long been in place to prevent never events, including mandatory "timeouts" in the operating room before operations begin to make sure medical records and surgical plans match the patient on the table. Other steps include using indelible ink to mark the site of the surgery before the patient goes under anesthesia. Procedures have long been in place to count sponges, towels and other surgical items before and after surgery, but these efforts are not foolproof, Makary notes. Many hospitals are moving toward electronic bar codes on instruments and materials to enable precise counts and prevent human error. Surgical checklists, pioneered at The Johns Hopkins Hospital, are also often in place.

Along with better procedures to prevent never events, better reporting systems are needed to speed up safety efforts, says Makary.

He advocates public reporting of never events, an action that would give consumers the information to make more informed choices about where to undergo surgery, as well as "put hospitals under the gun to make things safer."

Currently, he notes, hospitals are supposed to voluntarily share never event information with the Joint Commission that assesses hospital safety and practice standards, but that doesn't always happen.


'/>"/>

Contact: Stephanie Desmon
sdesmon1@jhmi.edu
410-955-8665
Johns Hopkins Medicine
Source:Eurekalert

Related medicine news :

1. 29 Johns Hopkins stem cell researchers awarded funding
2. Johns Hopkins African bioethics program receives 5-year continuation grant from NIH
3. Johnson & Johnson Violated FDA Order to Halt Sales of Transvaginal Mesh
4. Johns Hopkins researchers return blood cells to stem cell state
5. Johns Hopkins team finds ICU misdiagnoses may account for as many annual deaths as breast cancer
6. Johns Hopkins Armstrong Institute receives $8.9 million patient safety grant
7. Results from study of Mead Johnsons Enfamil® Human Milk Fortifier Acidified Liquid published in Pediatrics
8. Johns Hopkins scientists pair blood test and gene sequencing to detect cancer
9. The US Drug Watchdog Now Urges Women Who Suffered A Heart Attack Or Stroke After Using Yaz Yasmin Birth Control Pills To Contact The Johnson Law Group Immediately
10. The US Drug Watchdog Now Urges Any Woman Who Used The Birth Control Pills Yaz Or Yasmin And Then Had A Heart Attack Or Stroke To Call The Johnson Law Group----ASAP
11. In US first, Johns Hopkins surgeons implant brain pacemaker for Alzheimers disease
Post Your Comments:
*Name:
*Comment:
*Email:
(Date:3/29/2017)... ... 29, 2017 , ... An inventor from Raynham, Mass., knows ... in conjunction with my braces always rubbed against the inside of my cheeks, ... this problem." The O.B.S. was the result of his brainstorming. , This patent-pending ...
(Date:3/29/2017)... ... March 29, 2017 , ... HealthCareMandA.com will host an ... 20, 2017, at 1:00 PM ET. A recording of the webinar will also be ... Series. , Home health and hospice companies are still popular targets for healthcare investors. ...
(Date:3/29/2017)... (PRWEB) , ... March 29, 2017 , ... ... in many scientific laboratories. The assembly protocols involve many repetitive steps and often ... for automation, which enables the high-throughput needed, and results in a lower error ...
(Date:3/29/2017)... ... March 29, 2017 , ... Immunotherapy has emerged as one of ... and is touted to be the next revolution in our fight against this complex ... the form of immune checkpoint inhibitors such as PD-1 and PD-L1 inhibitors. , While ...
(Date:3/29/2017)... CA (PRWEB) , ... March 29, 2017 , ... Hamlin ... Northridge , is now offering laser dental treatments. Dental lasers are safe and effective ... dentistry expands patients’ options and can improve the overall quality of care. , Dr. ...
Breaking Medicine News(10 mins):
(Date:3/29/2017)... 29, 2017 Varian Medical Systems (NYSE: ... the second quarter of fiscal year 2017 following the close ... release will be followed by a teleconference available to all ... a link to the conference call webcast will be available ... the teleconference call and replay: ...
(Date:3/29/2017)... Research and Markets has announced the addition of the ... their offering. ... The ablation device global market is expected to grow at high ... Ablation is the minimally invasive therapeutic tissue excision procedure used ... removal, to the removal of abnormally conducting cardiac tissue in atrial ...
(Date:3/29/2017)... , March 29, 2017  Designers of primary cell ... solution size by 50% and extend battery life with ... management integrated circuit (PMIC) from Maxim Integrated Products, Inc. ... a low input voltage of just 0.7V for new ... Silver Oxide, as well as the more common Alkaline ...
Breaking Medicine Technology: