From operating on the wrong body part to the wrong patient, there are certain mistakes that medical professionals, along with members of the general public, agree should never happen. Unbelievably, such never events do occur with a 2013 study indicating that one out of every 12,000 U.S. patients who undergoes surgery will be the victim of an inexcusable medical error.
In an attempt to determine why surgical never events occur and how to prevent them, healthcare professionals are turning to one of the world’s leading medical hospitals, the Mayo Clinic. Medical researchers at Mayo recently released the results of a study, which appear in the journal Surgery, that provide valuable insight into why even the most experienced doctor or nurse may make an egregious error.
The study’s findings detail a total of 628 human factors that researchers identified as contributing to surgical never events. Overconfidence, stress, mental fatigue and poor communication and handoffs are all included among the most common error-producing human factors. Other factors detailed in the study include organizational culture, failures to follow safety protocols and staffing shortages.
In an effort to combat these identified human factors and prevent surgical errors, hospitals are encouraged to require that surgical teams review and confirm all aspects of a procedure prior to its start. Additionally, hospitals are advised to establish their own systems for tracking and investigating never events. Transparency on the part of hospitals, surgeons and nurses is key to helping prevent these types of medical errors.
For a patient who suffers harm and injury due to a never event, it’s important to understand what happened and why it happened. Keeping detailed records about one’s situation is crucial in the event an individual or his or her family decide to take legal action.
Source: Fierce Healthcare, “Human behavior behind most surgical errors,” Ilene MacDonald, June 9, 2015