Never Events...P O Day 356

Major medical-hospital errors are called Never Events. Examples would include operating on the wrong body part, operating on the wrong side of the body, and operaring on the wrong patient! In spite of systems in place to prevent these disasters, errors still occur. Mayo Clinic did an in-house investigation to try to learn why,

The obvious and predictable events contributed.

• Preconditions for action, such as poor hand-offs, distractions, overconfidence, stress, mental fatigue and inadequate communication.
• Unsafe actions, such as bending or breaking rules or failing to understand them. This category of errors includes confirmation bias, in which clinicians convince themselves they are seeing what they think they should be seeing.
• Oversight and supervisory factors, such as inadequate supervision, staffing deficiencies and planning problems.
• Organizational influences, such as problems within the organization'sl culture or operational processes.

 The committee said the staff shoud  develop a protocal like what flight crews do. There should be a time out in the operaitng room just before surgery and a check list that is gone through every time.  Poor communiction tends to be the root of the problem.  The Mayo Clinic estimates a Never Event occurs one in every 22,000 cases but in the general hospital industry the incidence is more like one in 12,000 cases. That sounds rare but nationwide that breaks down to approximately 268 cases a day!

The problem is that human beings are involved and we humans are subject to human error. We make mistakes. That's not to say having computers run things would be better, just different. Computers leave no room for decision making and  judgement but, in humans, judgement opens the door for poor judgement. Perhaps some kind of cross checking could work but I don't think there will ever be no Never Events.