Surgical “Never Events” Occur at Random

A new study concludes that surgical “never events” apparently transpire at random, and are unrelated to hospital or operating room (OR) safety measures.

Researchers at Nottingham University Hospitals (United Kingdom) conducted a comprehensive survey involving every National Health Service (NHS; London) Hospital Trust in England. 158 English NHS Hospital Trusts were contacted using Freedom of Information requests, and all responded by providing data on “never events” and surgical caseload between 2011 and 2014. In all, 742 such events were reported over a three-year period, out of a grand total of over three million operations.

The results showed that 'never events' happen once in every 16,423 operations, or 12.9 events per OR per year. Almost 50% of the surgical “never events” caused no or minimal harm, and only 7% of these events (or once in 238,939 operations) led to major harm. The rates reported by the NHS Hospital Trusts were similar to those reported in the United States. Importantly, the study found that the only major factor influencing the number of “never events” at any individual hospital was its size, and other measures of safety did not appear to be related to their occurrence. The study was published on November 23, 2015, in Anaesthesia.

“Whilst ‘never events’ certainly do continue to occur and on rare occasions can be catastrophic, they seem to be relatively unusual. We cannot exclude the possibility that there are significant variations in quality and safety of surgical care within NHS hospitals,” concluded lead author associate professor Iain Moppet, MD, of the division of clinical neuroscience. “Never Event occurrence may be related to a yet unmeasured set of safety behaviors, but Occam's razor would argue for a simpler explanation. Never Events are important, but as they are rare, apparently random events they are the wrong metric to gauge safety within the operating theatre.”

Never Events are defined as serious, largely preventable patient safety incidents that should not occur if the available preventative measures are implemented. The categories of ‘never events’ recognized in the UK consist of wrong site surgery, wrong implant/prosthesis, and retained foreign object post-operation.

Related Links:
Nottingham University Hospitals
UK National Health Service