Causes of never events during a surgical procedure

It is never easy to hear that you need surgery. After all, surgery carries with it several risks and complications no matter how minor or major it is. Patients in Pennsylvania rely on the experience and expertise of the surgeons about to perform the surgery on them. However, unfortunate errors could occur. Even if these errors or mistakes during a surgical procedure are minor, this could greatly impact the health and wellbeing of the patient. Therefore, it is essential for patients to understand the cause of these errors.

Major surgical errors are referred to as never events because they are occurrences that shouldn’t happen given the medical expertise of the surgeons and the credentials of the medical facility. Nonetheless, these never events do unfortunately occur and do cause patients much harm. According to a recent study by Mayo Clinic researchers, 69 never events were identified among the 1.5 million invasive procedures that were performed over the past five years.

This study detailed why these never events occurred, identifying the human behavior and environmental conditions involved. Based on the results, of these 69 never events, 24 included the wrong procedure, 22 were wrong site surgeries, five were putting in the wrong implant and 18 were leaving an object inside of the patient. Of all the never events analyzed in this study, none were fatal.

Based on this study, it was determined that never events occurred roughly 1 in every 22,000 procedures. Nearly two-thirds of these never events occurred during relatively minor procedures such as anesthetic blocks, line placements, endoscopy, radiology procedures and other soft tissue procedures.

With regards to certain human factors causing these never events, this study found four major factors. The first is actions such as poor handoffs, distractions, overconfidence, mental fatigue or inadequate communication. The second is unsafe actions, which includes bending or breaking the rules or even failing to understand them. The third is errors is oversight or supervisory, which also includes staffing deficiencies and planning problems. Finally, the fourth factor is organizational influences, which includes problems with organizational culture or the operational process at the facility.

Injured patients harmed by a negligent surgeon or hospital should understand that they have options available to them. It is important that patients take steps to understand their rights with regards to medical malpractice and seek guidance to protect their interests.

Source:, “How does human behavior lead to surgical errors? Researchers count the ways,” June 1, 2015