Surgeons Make at Least 4,000 ‘Never’ Errors per Year


At least 80,000 medical “never events” have occurred during hospital surgeries over the past two decades, according to a new study by Johns Hopkins University. A “never event” is defined as a mistake that should be preventable by basic procedural diligence, such as leaving a surgical implement inside a patient, performing the wrong procedure, operating on the wrong part of the body or even operating on the wrong patient altogether.

The numbers are disturbing for anyone who has an upcoming visit to the surgeon’s table: Foreign objects are left in a patient’s body an average of 39 times per week, while the wrong procedure or a procedure on the wrong body part are performed 20 times each per week. Operations on the wrong patient are more rare, occurring a reported 17 times over the two decades the study covers.

The mistakes are costly for the health care industry, resulting in 9,744 successful malpractice suits over 20 years, at a cost of $1.3 billion to the hospitals and their insurers. Of course, the human cost is much greater– of the malpractice claims, 59 percent involved temporary injury, 33 percent involved permanent injury and 6.6 percent involved the death of a patient.

All told, the researchers extrapolate the data to estimate that an astonishing 4,000 adverse events that should never, ever happen take place each year.


Procedural Challenges

Robert M. Keese

The distinction between regrettable but understandable doctor error and “never events” is a critical one. “There are mistakes in health care that are not preventable. Infection rates will likely never get down to zero even if everyone does everything right, for example,” said study leader Marty Makary, M.D., M.P.H., in a press release. “But the events we’ve estimated are totally preventable. This study highlights that we are nowhere near where we should be and there’s a lot of work to be done.”

Worse, the study acknowledges that it almost surely has under-reported the amount of preventable errors. “As with any medical malpractice study, the number of errors is probably much higher than 4,000, since researchers can only study reported events,” write attorneys for the California firm Girardi Keese. “Many patients will never file a claim or understand what caused their injury. This is especially true in cases involving surgical objects left inside a patient.”

The Hopkins study notes that as many as one in four sponges left inside a patient will never be discovered.


Recourse Through the Legal System

People in every profession make mistakes, but the stakes of a mishap are much higher for patients on the operating table whose lives are literally in the hands of their surgeons. Unfortunately, as the Hopkins study shows, whatever safeguards are in place to stop preventable errors that should never happen under any circumstances are not doing the job.

“Hospitals have procedures to count and re-count surgical objects, they have electronic charts and surgical ‘time-outs’ to ensure that the patient is the right patient and the surgery is the right surgery,” the Girardi Keese attorneys say. “Yet, it is obvious this is not enough.”

Sometimes, forcing doctors and hospitals to take financial responsibility for the harm their negligence has caused can be the only way to ensure better diligence in the future. “Whether a surgeon is simply too tired or a nurse fails to double-check the charts, they must be held accountable for their errors,” write the attorneys. “Through a medical malpractice lawsuit, a victim can recover compensation for medical bills, pain and suffering, and other damages. Perhaps more importantly, a medical malpractice lawsuit makes a strong statement that we will not accept negligent medical care.”

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