Tags: never | event | surgery | errors | wrong | site

Study Reveals Surgeons Sometimes Operate on Wrong Body Part

By    |   Friday, 12 June 2015 02:58 PM

They’re called “never events” — surgical errors that should simply never happen. But new research finds they are surprisingly common.

In about one in 100,000 surgeries, doctors make a "wrong site" error — for example, they operate on the wrong side of a person's body, or sometimes even on the wrong person. What’s more, doctors leave something (like a medical sponge or instrument) in the patient’s body after surgery in about one of every 10,000 procedures, according to the analysis published online in the journal JAMA Surgery.

The root cause of most errors: Poor communication among medical staff, the researchers found.
"Never events are, fortunately, very rare," said lead researcher, Susanne Hempel, co-director of the Evidence-based Practice Center at the RAND Corporation, a nonprofit global policy think tank.

But that makes it difficult to collect enough data on these events and how to prevent them, she said.
Hempel and her colleagues conducted the review for the U.S. Veterans Affairs National Center for Patient Safety, "to evaluate the state of the evidence 10 years after the introduction of the Universal Protocol, a concerted effort to improve surgical safety," she told Live Science.

The findings are based on a review of 138 studies, published from 2004 to 2014, that reported on at least one of three types of never events: wrong-site surgery, leaving an item behind in a person during surgery, and surgical fires.

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'Never events' - surgical errors that should simply never happen - are more common than you might think, new research suggests.
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Friday, 12 June 2015 02:58 PM
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