Common Surgical Never Events

Healthcare facilities are very active institutions. Each part must be functioning correctly, from delivery systems and issues of Managed Care and Centers for Medicare and Medicaid Services (CMS), to the National Quality Forum (NQF). These different parts of healthcare facilities are constantly dealing with many different situations that arise. Sometimes circumstances that should not take place occur. These types of circumstances are known as Never Events. As these events rise in number, the safety of patients is decreased; this forces the healthcare facility to find new and improved ways to ensure the safety of patients and reduce medical errors.

With all of the possible problems that could occur during surgery, a wrong-site, wrong-patient mistake is one that should never arise. Nightingale Community Hospital (NCH) fully understands the importance of doing away with these errors and has set up protocol to work towards this goal. While the protocol is in place, it is not fully compliant with Joint Commission (JC) standards.

Wrong-site surgery is a serious and preventable occurrence, however, it continues to be a problem in

Lastly, in the surgery theatre, misidentification may happen due to the same factors formerly mention plus failure to mark site/side of surgery, failure to properly perform time-out, and multiple surgical teams (Chan et al., 2010). To analyze the risk for these errors, few factors will be analyzed including human factors (staffing, scheduling, supervision, and qualification), equipment and technology (scanners, computers, and software), Communication (between staff and patients, between staff, between staff and physician, between physician and patient, and between units), environmental factors (physical, safety, security, and preparedness), and procedures and policies (planning, staff education, patient education, protocols, patient identification, and patient observation) (Chan et al., 2010).

I am gonna tell you how it is before surgery. So before the surgery so your mom and your dad and all the family that comes. Come in your room and make sure your ok. And tell you that you're gonna be ok because they are your family. so they want to make sure that you're ok with the doctors can touch

Not all surgical procedures are the same, each procedure necessitates very specific skills, expertise, knowledge, and

Each year medical errors cause more than 400,000 American deaths and at least 10-20 times that number experience serious harm. Researchers say that is equivalent to “three 747 airplanes crashing each day.” Medical errors rank as the third-leading cause of death in America. Therefore, patient safety is a national concern.

In 2008, it was estimated that “medical errors total more than $19.5 billion” (Andel, 2012, p. 12). It is important to address and solve this problem at this time because the National Quality Forums (NQF) “never events” considers such events. Never events are events that occur that should have never occurred in the first place. Reducing and eventually eliminating wrong site surgeries will help improve patient safety in the operating room and become a leading example in improving patient safety in all aspects of healthcare.

Form precise neurosurgery through the leg and heart valve replacement without opening the chest to robotic surgery through the belly button and custom joint replacement procedures, Tallahassee Memorial Hospital Main OR continuously provide patients with the best possible care. TMH OR offers a variety of surgical interventions. However, regardless of the surgical or interventional procedure, in most cases are required a sterile technique, a legal formed consent and administration of medications. Therefore, my goals, which I completed, for week # 3 in the TMH Main OR are:

1) According to the World Health Organization (WHO), how could at least half a million deaths due to surgical error be prevented every year?

According to the article Thousands of Mistakes Made in Surgery Every Year by Jennifer Warner from WebMD Health News, more than 4,000 mistakes occur in surgery every year that could have been prevented. These mistakes cost approximately $1.3 million dollars in medical malpractice payouts. This is a more than preventable act. Researchers frequently refer to these events as “never events” because they should simply never occur. Never events include incidents such as performing the wrong procedure or even leaving a medical sponge in the patient after surgery. Between the years of 1990 and 2010, never events occurred about 10,000 time in the United States. Each week a sponge or towel is left inside

An 82 year old patient required the operation to stem the flow of bleeding from her brain to her skull. The surgeon immediately started the procedure off incorrectly by drilling a hole on the wrong side of the patient's skull. This action occurred despite the fact that a CAT scan, performed only moments before, indicated that the bleeding was happening on the left side of the brain. The mistake was caught early on, and the resident surgeon closed the initial hole and proceeded to the correct side of the patient's head. Although the patient survived the surgery in fair condition, two other similar incidents had occurred within the last year, one of which had resulted in the death of an 86 year old man.

Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission

Whether the surgeon is a resident or an experienced attending, in the process of performing any surgery, mistakes are inevitable. However, in the case of the attending, the quantity and nature of the error should be less frequent than that of the resident. Among the interns, the three most common errors are technical, judgmental, and normative; and among attendings the quasi-normative error is most common. Thus, a technical error is defined as any error that is reported and treated immediately. When this does not happen, the interns level of training is questioned. In the case of judgmental error, an incorrect

One might think of surgery as simple as going to the hospital and receiving a complex operation that saves ones life or improves their quality of life. What most people do not realize is the hardships that those people go through unless they had surgery performed on them themselves, and same thing for the surgeons it is not easy for them as well, even though they are professional and highly trained.