The healthcare industry has identified certain acts of malpractice, which are so egregious, there is universal agreement that they should never occur under any circumstances. These acts of malpractice include leaving foreign objects (eg., sponges) in the patient’s body during surgery, performing the wrong surgical procedure, operating on the wrong body part, and the like. These types of medical malpractice are known as “never events” — meaning they should never happen. Unfortunately, research data suggests that the more appropriate name for these acts of malpractice would be “way-too-often events.”
According to a study made public in December, 2012, Johns Hopkins patient safety researchers conducted what was described as a “cautious and rigorous analysis” of U.S. medical malpractice claims. Their study found that 80,000 of the so-called “never events” occurred in U.S. hospitals from 1990 through 2010. Even more troubling, the researchers believe this figure likely underestimates the frequency of the problem.
The researchers concluded that a foreign body is left in the patient after surgery in the U.S. approximately 39 times every week. They also found the wrong surgical procedure is performed on a patient 20 times a week, and the wrong body part is operated also operated on 20 times per week. It should also be noted that these estimates of medical negligence only include surgical malpractice — not other types of “never events” which apply in other healthcare settings. The study went on to find the so-called “never events” caused death in nearly 7 percent of patients, permanent injury in 33 percent, and temporary injury in 59.2 percent.
The frequency with which these “never events” occur in today’s healthcare setting is astounding, given that, as the study leader noted, the “never events” are medical errors which are “totally preventable.” The researchers estimated that 4,044 surgical never events occur in the United States each year, using published rates of adverse surgical events resulting in a malpractice claim from information obtained from the National Practitioner’s Data Bank (“NPDB”) (a national repository of information relating to medical malpractice claims in the U.S.).
By law, hospitals are required to report never events that result in a settlement or judgment to the NPBD. It is widely believed, however, that hospitals often fail to report these events. Accordingly, the actual incidence of these surgical errors is likely significantly greater than this this report suggests.
Hospitals should have policies and procedures in place which would prevent these inexcusable errors. However, as the study would suggest, apparently too often these policies and procedures are improperly developed, negligently implemented, absent altogether, or just plain ignored.
Clearly, something more must be done. At the very least, the incidence of these “never events” should be made public with respect to each hospital, so that patients can make informed decisions about where they want to seek care. One would hope that such public disclosure would incentivize the hospitals to take the steps necessary to ensure that these inexcusable errors are eliminated. This type of public disclosure is unlikely, however, given the power and influence of the healthcare industry. So unfortunately, for now we have no choice but to expect thousands of surgical “never events” to continue inflicting human suffering and death on U.S. healthcare consumers each year. The victims will continue to have no recourse other than to file a medical malpractice claim which can help them find some accountability, but never fully undo the life-altering consequences inflicted upon them.
Related articles:
Medical Malpractice Fact Sheet
http://www.hopkinsmedicine.org/news/media/releases/johns_hopkins_malpractice_study_surgical_never_events_occur_at_least_4000_times_per_year