What is a ‘never event’ in surgery?

Some mistakes should NEVER happen if the surgical team follows the rules.

People have thousands of surgerical procedures in Connecticut hospitals each year. Most of those surgeries go as planned. But sometimes complications arise. Sometimes mistakes are made, such as nicking an artery or organ or misjudging anesthesia. Even a minor surgery error can have dire consequences.

In the medical community, certain errors are referred to as “never events” because they should NEVER happen if surgeons and support staff adhere to protocol. One example is operating on the wrong part of the body. In the legal community, these inexcusable errors have another name – medical malpractice.

What are the ‘never events’ in surgery?

Simply put, never events are surgical mistakes that should not happen. Ever. When they do, it is a sign of larger patient safety concerns. It means one or more medical professionals bypassed the checks and balances that are in place to prevent such mistakes.

The following are considered never events in surgery:

• Wrong site — Operating on the wrong side (right leg vs. left leg), the wrong body part (removing a healthy organ instead of the diseased one), or the wrong location (upper spine instead of lower spine)   
• Wrong procedure — Performing the wrong operation (e.g., patient was supposed to have hernia repair, but spleen was removed)  
• Wrong patient – Performing the scheduled procedure on the wrong person because of similar names or other mix-up

Fortunately, these errors are not common – less than one per 100,000 operating room procedures. Yet with 53 million surgeries in the U.S. each year, that still means that more than 500 patients wake up from surgery to learn their doctors have ruined their lives forever. The number is surely higher if never events in outpatient surgery and nonsurgical never events (such as wrong medication) are counted.

If it’s a ‘never’ event, how does it keep happening?

All hospitals have safety protocols in place to prevent wrong-site, wrong-procedure and wrong-patient errors. For example, the surgical site may be marked in indelible ink. In the pre-surgical consultation, the patient verifies that it is the correct site and initials it. A nurse double-checks the chart and asks the patient to give their name and the reason for surgery. The anesthesiologist also confirms. And so on.

Just like a rocket launch, there are multiple checkpoints and multiple personnel who must give the affirmative. But then the unspeakable happens, and the investigation reveals where it all went wrong. Maybe “X” marked the spot that was NOT to be operated on. Maybe the patient was already groggy from anesthetic when asked to sign off. Maybe somebody checked a box without actually checking the patient or the chart. And so on.

It’s the textbook definition of medical malpractice

No amount of money can make up for losing a healthy limb or organ, or the ordeal of having to undergo more surgery to mitigate the damage, or the profound loss of a loved one due to preventable medical error. Never events are not “honest mistakes.” They are almost always medical malpractice. Someone didn’t do their job.

If you were the victim of a never event – or the victim of other medical negligence that is less clear-cut — you retain the right to file a medical malpractice claim against the medical facility, the surgeon and others who might have played a part in your situation. An attorney will investigate the medical charts from the very first doctor visit and the circumstances surrounding the incident. If there are indications of malpractice, the attorney will file a civil lawsuit to preserve your rights. A successfully litigated claim could provide you with the compensation you need for medical care, lost wages and other damages to which you might be entitled for the injuries you suffered.

In additional to any monetary judgment you might receive, a lawsuit could prompt necessary changes that could prevent another family from going through what you went through.