Incidence of surgical ‘never events’ analyzed

Wrong-site surgery, retained surgical items, and surgical fires—termed “never events”—continue to occur despite numerous patient safety initiatives.

Researchers from the Southern California Evidence-Based Practice Center, RAND Corporation, Santa Monica; Veterans Affairs Greater Los Angeles Healthcare system; and the University of California School of Medicine, Los Angeles, examined the incidence and root causes of and interventions to prevent wrong-site surgery, retained surgical items, and surgical fires since 2004, when the Universal Protocol was implemented.

Analyzing data from nine databases, the researchers found that current estimates for wrong-site surgery and retained surgical items are 1/100,000 and 1/10,000 procedures, respectively. However, the estimates are imprecise and vary across sources and specialties.

Despite promising approaches for preventing events, such as education, team training, and data-matrix-coded sponge-counting systems, evidence to support any particular intervention was limited. A frequently reported root cause was inadequate communication.

Evidence for preventing surgical fires was insufficient, and the effect of interventions could not be estimated.

The researchers concluded that distinct methodologic challenges impede the analysis of never events and may necessitate different evaluation methods.

—Hempel S, Maggard-Gibbons M, Nguyen D K, et al. Wrong-site surgery, retained surgical items, and surgical fires. JAMA Surg. Published online June 10, 2015.

http://archsurg.jamanetwork.com