The Mayo Clinic found that 'never events' occurred at their campus during 1 of every 22,000 procedures. But the national rate for never events in much higher. A 2013 study published in Surgery estimated it to be closer to 1 in 12,000 procedures.
Never events are the kind of mistakes that should never happen.
JAMA Surgery recently published another study this week that took a systematic review of surgical never events, including wrong-site surgery, retained surgical items and surgical fires, in order to determine why they still happen despite the implementation of patient safety efforts at hospitals across the country.
The study found that poor communications is behind most of these events, a problem that was also identified by the Mayo Clinic researchers.
The Mayo study additionally identified a series of as many as nine missteps that can lead to a surgical error.
The latest research shows that medical errors contribute to the deaths of 210,000 to 400,000 patients annually, considerably more than the 44,000 – 98,000 figure cited in the Institute of Medicine’s landmark 1999 report.
Analyzing the Institute of Medicine’s estimate of 98,000 per year means that about 260 patients are affected a day.
In order to prevent these errors, hospitals must change their patient safety culture throughout their organizations, not just in the operating room. This culture must encourage all workers to speak up when they spot a potential safety problem.
Physicians often don’t feel comfortable sharing mistakes for fear of shame or loss of reputation. However, if this starts with the top, hospitals will be able to talk about the importance of patient safety and the acceptability of talking about mistakes. Anytime the culture of an institution is being changed, it has to come from the top.
Some researchers assert that another way to solve this epidemic is to eliminate distractions and adopt best practices followed by the aviation industry.
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