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Medical Malpractice Blog Post

Preventable Medical Error: Never Events

We talked recently about wrong site surgery, a type of wholly unnecessary medical mistake termed a never event. While steps are taken each year to reduce the occurrence of malpractice events, they still occur too often — as a recent study from John Hopkins Medicine reveals.

What are never events?

According to the Agency for Healthcare Research and Quality (AHRQ), the term never event was created in 2001 by Ken Kizer, MD, a former officer of the National Quality Forum (NQF). The term refers to medical mistakes that should simply never happen. The list has grown to include errors in six categories:

  • Patient protection
  • Care management
  • Criminal
  • Surgical
  • Product or device
  • Environmental
  • Radiologic

In December 2012, John Hopkins Medicine compiled results of a critical review of reports received between 1990 and 2010 by the National Practitioner Data Bank (NPDB), a federal repository of malpractice claims. While researchers believe their numbers are conservative, they made the following estimates:

  • Each week in the United States surgeons perform 20 wrong site and 20 wrong procedure surgeries
  • Surgical implements are left inside a body 39 times each week
  • Approximately 80,000 never events occurred during the 20-year study period
  • More than 4,000 surgical never events occur each year
  • Over the study time period, 9,700 malpractice claims were paid at a cost of $1.3 billion; the human price was much higher—
    • Ÿ 59 percent of victims experienced temporary injury
    • Ÿ 33 percent suffered permanent injury
    • Ÿ More than six percent died

These serious mistakes hit close to home. In December 2012 alone, the California Department of Public Health (CDPH) cited and fined area hospitals for 12 mistakes likely to cause serious injury or death.

Despite ongoing attempts to improve precautionary practices, consumers and healthcare providers agree, never events occur far too often.

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2550 Fifth Avenue, 11th Floor
San Diego, California, 92103-6612 USA