Skip to main content

Incidence of ‘Never Events’ and Common Complications

  • Chapter
  • First Online:
Patient Safety in Surgery

Abstract

The incidence of ‘never events’ is challenging to quantify due to the remaining confusion that lies between the NQF and the CMS definitions. The former defines patient - centered events that must never occur, most being at least potentially preventable. The later is more financially driven and penalizes hospitals in which these events, in most part non preventable, occur. It is crucial that the general public understands the differences so as to avoid future law suits for non preventable never events occurrences. Physicians must drive the universal implementation of a culture of patient safety. This process should focus on positive behaviors with an emphasis on ‘always events’. These events should be standardized and validated.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 89.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Hadjipavlou AG, Marshall RW. Wrong site surgery: the maze of potential errors. Bone Joint J. 2013;95-B(4):434–5. doi:10.1302/0301-620X.95B4.31235.

    CAS  PubMed  Google Scholar 

  2. Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C, Institute of Medicine. To err is human: building a safer health system. Washington, DC: The National Academies Press; 2000. ISBN-13: 978-0-309-26174-6 (800-624-6242).

    Google Scholar 

  3. Lembitz A, Clarke T. Clarifying “never events” and introducing “always events”. Patient Saf Surg. 2009;3:26.

    PubMed Central  PubMed  Google Scholar 

  4. Brilli RJ, McClead RE Jr, Crandall WV, Stoverock L, Berry JC, Wheeler TA, Davis JT. A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality. J Pediatr. 2013;163(6):1638–45.

    Google Scholar 

  5. Schoenfeld AJ, Ochoa LM, Bader JO, Belmont PJ. Risk factors for immediate post-operative complications and mortality following spine surgery: a study of 3475 patients from the national surgical quality improvement program. J Bone Joint Surg. 2011;2011:1577. doi:10.2106/JBJS.J.01048.

    Google Scholar 

  6. Basey AJ, Krska J, Kennedy TD, Mackridge AJ. Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Qual Saf. 2014;23(1):17–25. doi:10.1136/bmjqs-2013-001978.

    PubMed  Google Scholar 

  7. Bates DW, Lucian LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280(15):1311–16. doi:10.1001/jama.280.15.1311.

    CAS  PubMed  Google Scholar 

  8. Peikari HR, Zakaria MS, Yasin NM, Shah MH, Elhissi A. Role of computerized physician order entry usability in the reduction of prescribing errors. Healthc Inform Res. 2013;19(2):93–101. doi:10.4258/hir.2013.19.2.93.

    PubMed Central  PubMed  Google Scholar 

  9. Borycki E. Trends in health information technology safety: from technology-induced errors to current approaches for ensuring technology safety. Healthc Inform Res. 2013;19(2):69–78. doi:10.4258/hir.2013.19.2.69.

    PubMed Central  PubMed  Google Scholar 

  10. Mogensen CB, Olsen I, Thisted AR. Pharmacist advice is accepted more for medical than surgical patient in an emergency department. Dan Med J. 2013;60(8):A4682.

    PubMed  Google Scholar 

  11. Cobb TK. Wrong site surgery – where are we and what is the next step? Hand (NY). 2012;7:229–32. doi:10.1007/s11552-012-9405-5.

    Google Scholar 

  12. Ring DC, Herndon JH, Meyer GS. Case records of The Massachusetts General Hospital: Case 34-2010: a 65-year-old woman with an incorrect operation of the left hand. N Engl J Med. 2010;363(20):1950–7.

    CAS  PubMed  Google Scholar 

  13. Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf. 2014;23(4):299–318.

    Google Scholar 

  14. Cima RR, et al. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80–7. doi:10.1016/j.jamcollsurg.2007.12.047.

    PubMed  Google Scholar 

  15. Lincourt AE, Harrell A, Cristiano J, Sechrist C, Kercher K, Heniford BT. Retained foreign bodies after surgery. J Surg Res. 2007;138(2):170–4.

    PubMed  Google Scholar 

  16. Greenberg CC, Regenbogen SE, Lipsitz SR, Diaz-Flores R, Gawande AA. The frequency and significance of discrepancies in the surgical count. Ann Surg. 2008;248(2):337–41. doi:10.1097/SLA.0b013e318181c9a3.

    PubMed  Google Scholar 

  17. Cima RR, Kollengode A, Storsveen AS, Weisbrod CA, Deschamps C, Koch MB, Moore D, Pool SR. A multidisciplinary team approach to retained foreign objects. Jt Comm J Qual Patient Saf. 2009;35(3):123–32.

    PubMed  Google Scholar 

  18. Cross MB, Boettner F. Pathophysiology of venous thromboembolic disease. Semin Arthro. 2009;20:210–16. doi:10.1053/j.sart.2009.10.002.

    Google Scholar 

  19. Gilmore R, Doyle M, Holden F, White B, O’Donnell J. Activated protein C resistance, factor V Leiden and assessment of thrombotic risk. Ir Med J. 2008;101(8):256–7.

    CAS  PubMed  Google Scholar 

  20. Morris CD, Creevy WS, Einhorn TA. Chapter 12: Pulmonary distress and thromboembolic conditions affecting orthopaedic practice. In: Buckwalter JA, Einhorn TA, Simon SR, editors. Orthopaedic basic science: biology and the biomechanics of the musculoskeletal system. 2nd ed. American Academy of Orthopaedic Surgeons, Chicago, IL. 2000.

    Google Scholar 

  21. Itatsu K, Sugawara G, Kaneoka Y, Kato T, Takeuchi E, Kanai M, Hasegawa H, Arai T, Yokoyama Y, Nagino M. Risk factors for incisional surgical site infections in elective surgery for colorectal cancer: focus on intraoperative meticulous wound management. Surg Today. 2013. Epub ahead of print.

    Google Scholar 

  22. Pruzansky JS, Bronson MJ, Grelsamer RP, Strauss E, Moucha CS. Prevalence of modifiable surgical site infection risk factors in hip and knee joint arthroplasty patients at an urban academic hospital. J Arthroplasty. 2014;29(2):272–6.

    Google Scholar 

  23. Fakih MG, Heavens M, Ratcliffe CJ, Hendrich A. First step to reducing infection risk as a system: evaluation of infection prevention processes for 71 hospitals. Am J Infect Control. 2013;41(11):950–4.

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Cyril Mauffrey MD, FACS, FRCS .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2014 Springer-Verlag London

About this chapter

Cite this chapter

Cross, M.B., Mauffrey, C. (2014). Incidence of ‘Never Events’ and Common Complications. In: Stahel, P., Mauffrey, C. (eds) Patient Safety in Surgery. Springer, London. https://doi.org/10.1007/978-1-4471-4369-7_2

Download citation

  • DOI: https://doi.org/10.1007/978-1-4471-4369-7_2

  • Published:

  • Publisher Name: Springer, London

  • Print ISBN: 978-1-4471-4368-0

  • Online ISBN: 978-1-4471-4369-7

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics