What is true about 'never events' in medical care?

Understanding "Never Events" in Medical Care

Systems errors are the root cause of the majority of "never events," making option E the correct answer. 1, 2

What Are "Never Events"?

Never events are serious patient safety incidents that are:

• Wholly preventable when appropriate safeguards are in place
• Clearly identifiable
• Serious in their consequences for patients
• Used as a surrogate measure of healthcare quality 1

Analysis of Common Never Events

Types of Never Events

The most frequently reported never events include:

• Wrong-site surgery (40.25% of all never events) 2
• Retained foreign objects (27.75%) 2
• Wrong implant or prosthesis (13.09%) 2
• Non-surgical/infrequent events (18.9%) 2

Retained Surgical Instruments

• Retained surgical instruments can indeed be prevented by using surgical counts, but this is only one preventive measure in a larger systems-based approach 3
• Retained items occur at least once a year in major hospitals performing 8,000-18,000 surgeries annually 3
• The most commonly retained items are vaginal swabs (30.63%), surgical swabs (18.20%), and guidewires (16.87%) 2

Wrong-Site Surgery

• Risk factors for wrong-site surgery do include time pressure and morbid obesity, but these are just two among many systemic factors 4, 5
• Laterality problems (wrong side) account for 22.95% of wrong-site surgeries 2
• Machine learning analysis has identified multiple contributing factors to wrong-site surgeries, with some combinations increasing risk by up to 13,600% in certain surgical specialties 5

Surgical Specialty Involvement

• The surgical subspecialty most commonly involved in reported wrong-site surgery is not neurosurgery, making option D incorrect 4, 2
• Orthopedic surgery is one of the most involved specialties, accounting for 14.16% of all never events 4

Likelihood of Wrong-Site Error

• There is no evidence supporting a 10% chance that surgeons working on symmetric anatomic structures will be involved in a wrong-site error during their career, making option C incorrect 1, 4, 2

Root Causes of Never Events

Systems Errors

• Systems errors are indeed the root cause of the majority of "never events" 1, 5
• A shift from a culture of blame to a culture of collaborative and collective learning is recommended to address these system failures 6
• The TRACK principle (Transparency, Respect, Accountability, Continuity, and Kindness) is recommended for handling medical errors 6

Prevention Strategies

• Prevention requires consistent application of reliable and standardized processes of care 3
• Safety standards should be adjusted based on risk assessment for each operating room 5
• A multidisciplinary team dedicated to medication management safety is essential for preventing medication-related never events 6

Conclusion

Never events are preventable adverse incidents that should not occur when proper systems and safeguards are in place. While individual factors like surgical counts, time pressure, and morbid obesity play roles in specific types of never events, the evidence clearly shows that systems errors are the fundamental root cause of the majority of these incidents, making option E the correct answer.