“Never Events” in Surgery Stephen D. Cassivi, MD MSc FRCSC FACS Professor of Surgery Vice Chair – Department of Surgery

Financial Relationship / Conflict of Interest Disclosure Statement I have NO financial relationships or potential conflicts of interest to report

Audience Response Questions Never Events in Surgery

Which of these following events is the most commonly reported ‘Never’ event? A.Abduction of inpatient B.Inpatient Suicide C.Wrong-site Surgery A.Abduction of inpatient B.Inpatient Suicide C.Wrong-site Surgery Source: 2009 Joint Commission Report Never Events in Surgery

Which of these following events is the most commonly reported ‘Never’ event? A.Abduction of inpatient B.Inpatient Suicide C.Wrong-site Surgery A.Abduction of inpatient B.Inpatient Suicide C.Wrong-site Surgery Source: 2009 Joint Commission Report Never Events in Surgery

Of the following 4 surgical ‘Never Events’, which is the most common? A.Surgery on the wrong body part B.Surgery on the wrong patient C.Unintended retention of a foreign object D.Wrong surgical procedure performed A.Surgery on the wrong body part B.Surgery on the wrong patient C.Unintended retention of a foreign object D.Wrong surgical procedure performed Never Events in Surgery

Of the following 4 surgical ‘Never Events’, which is the most common? A.Surgery on the wrong body part B.Surgery on the wrong patient C.Unintended retention of a foreign object D.Wrong surgical procedure performed A.Surgery on the wrong body part B.Surgery on the wrong patient C.Unintended retention of a foreign object D.Wrong surgical procedure performed Never Events in Surgery

Of the following 4 surgical ‘Never Events’, which is associated with the highest average malpractice payments? A.Surgery on the wrong body part B.Surgery on the wrong patient C.Unintended retention of a foreign object D.Wrong surgical procedure performed A.Surgery on the wrong body part B.Surgery on the wrong patient C.Unintended retention of a foreign object D.Wrong surgical procedure performed Source: Surgery 2013:153; Never Events in Surgery

Of the following 4 surgical ‘Never Events’, which is associated with the highest average malpractice payments? A.Surgery on the wrong body part B.Surgery on the wrong patient C.Unintended retention of a foreign object D.Wrong surgical procedure performed (~ $230,000/case) A.Surgery on the wrong body part B.Surgery on the wrong patient C.Unintended retention of a foreign object D.Wrong surgical procedure performed (~ $230,000/case) Source: Surgery 2013:153; Never Events in Surgery

Of the 5 surgical ‘Never Events’, which one, in your opinion, can we improve upon the most? A.Intraoperative or immediately postoperative death in an ASA class I patient B.Surgery on the wrong body part C.Surgery on the wrong patient D.Unintended retention of a foreign object E.Wrong surgical procedure performed A.Intraoperative or immediately postoperative death in an ASA class I patient B.Surgery on the wrong body part C.Surgery on the wrong patient D.Unintended retention of a foreign object E.Wrong surgical procedure performed Never Events in Surgery

“Never Events” in Surgery Stephen D. Cassivi, MD MSc FRCSC FACS Professor of Surgery Vice Chair – Department of Surgery

“Never Events”

“The defense strenuously objects.”

“Never Events” Ken Kizer, MD MPH Founding President and CEO – National Quality Forum

Which of these have you done in the past year? A.Paid for an Insurance Policy B.Purchased a Lottery ticket C.Both A & B D.Neither A or B A.Paid for an Insurance Policy B.Purchased a Lottery ticket C.Both A & B D.Neither A or B Never Events in Surgery

Negative Framing Daniel Kahneman, BA PhD 2002 Nobel Prize in Economics When the consequences of failing to act are mentally vivid, humans are more strongly inclined to take action when the actions are labeled so as to convey the loss avoided rather than the benefit gained.

“Never Events” Wrong-Site Surgery ~ 1/112,000 surgical procedures ~ 4000 cases / year

“Never Events” 29 “Serious Reportable Events” Growing list of: “Non-Reimbursable Serious Hospital-Acquired Conditions”

NQF – SREs 1.Surgery on the wrong site 2.Surgery on the wrong patient 3.Wrong surgical procedure 4.Unintended retained foreign object 5.Death in an ASA I patient Device related death Hospital-acquired burns Falls Pressure ulcers (stage 3 or 4)

CMS Non-Reimbursable Serious Hospital-Acquired Conditions Beyond the NQF Catheter-associated UTI Vascular catheter-associated infection SSI after CABG SSI after Bariatric surgery SSI after orthopedic surgery DVT in total knee or hip replacement

“Never Events”

“Never Events” Steps to take

1. Recognize that it’s not just on you.

“Never Events” Steps to take 1. Recognize that it’s not just on you.

“Never Events” Steps to take 1. Recognize that it’s not just on you. 2. Develop and standardize Evidence-based / Best Practices

“Never Events” Best Practices

“Never Events” Steps to take 1. Recognize that it’s not just on you. 2. Develop and standardize Evidence-based / Best Practices 3. Nurture a culture of safety

“Never Events” Measured Optimism “Fortunately, in the last six years, we’ve witnessed remarkable improvements and innovative solutions emerge in response to review of these Serious Reportable Events.” Dr. Janet Corrigan NQF President and CEO