1. Surgical “Never Events”
Serious Medical Errors in Surgery that Should Never Happen to a Patient
Hello, I am Melody Shaw and I want to talk to you today about Surgical Never events, and how we as nursing staff can help prevent them.
Melody Shaw

2. Surgical Error Blamed on Circulating Nurse
15 year old boy goes into surgery to remove the right side of the brain to prevent epileptic seizures
The surgeon entered the left side of the brain, and started removing part of the left brain.
The patient came out of surgery and the parents were informed of the mistake as “minor and inconsequential”
After graduating high school, the boy was placed in an assisted living facility
The family filed a lawsuit and won $11 Million but that will not touch the pain and suffering they have had to endure
This is one of the many stories that I have read about mistakes in the OR. The part that caught my attention is that the nurse is also held responsible for the surgical mistake. Why is the nurse blamed, rather than the surgeon who completed the surgery. In 2004, JCAHO established Universal Protocol that includes three steps: pre-surgical time out briefings, marking the surgical site, and confirming patients identity (O’Reilly, 2013). The nurse has the responsibility to ensure that these steps are followed, and to chart that these items have been completed.
Legal EagleEye, 2013

3. Statistics of Surgical “Never Events”
Type Of “Never Event”
Cases
Average Payout
Wrong Procedure
2,447
$232,035
Wrong Site
2,413
$127,159
Wrong Patient 27
$109, 648
Retained Foreign Body
4,857
$86,247
Surgical “Never Events” include wrong procedure, wrong site, wrong patient, and surgical tools being left in the patient. The numbers increased until 2004 when the Joint Commission established universal protocols. They also have National Patient Safety Goals established each year. It has a full explanation on what to complete pre, during and post procedure(JCAHO, 2013) The Joint Commission accrediates over 19,000 hospitals, and in those hospitals the number of “never events” has gone down from 52% to 19% (O’Reilly, 2013)
About 80 times each week a surgical “Never Event” occurs
Annual Rate of 4,082 surgical “Never events”
Approximately 1 surgical “Never Event” occurs every 12,248 Surgeries
Average payout each “Never Event” is $133,055 which is over $5 Million
(O’Reilly, 2013)

4. “Time Out”
Each hospital that follows the Joint Commission’s recommendations of Universal Protocol comes up with their standard “Time Out” procedure. The first thing that should be completed before the patient has entered the operating room, and before they are medication is the surgeon marks the correct location of the surgery and initials it. The patient should be alert so they are able to confirm the location. Once the patient is moved into the operating room, the surgical team should pause and confirm the patients name, procedure and location before starting the procedure. I have witnessed this during clinicals, and everyone had to be quiet, listen and verify. The nurse charted the members in the room and that time out was completed.

5. A Simple Surgery Gone Wrong
A C-Section was performed on a patient and she was discharged
Her stomach started growing again over the next month, and by the 6th week her bowels had completely shut down
A surgical sponge was left in her abdomen
She had to stay in the hospital for 3 weeks and still takes medication to regulate her bowels today
She was also informed it is not recommended for her to have another child
Thousands of patients a year leave the OR with a surgical item in them. This could have been avoided simply by doing a sponge count before and after the surgery. The patient usually carries the sponge in their body for months before noticing the problem. There is no national standard to follow and track the surgical instruments. Technology has allowed some facilities to ensure no sponges are left in the patients. With budget cuts and reform, it is hard to afford the $8 per surgery for a tracker tag on each sponge. Traumas and hectic surgeries allow increase in miscounted sponges. If a cost analysis was completed on the $8 tracker sponges rather than a $150,000 lawsuit for each lost sponge, maybe the hospital management would realize that the cheaper and safer route would be the tracker sponges.
(Eisler, 2013)

6. The Family and a Lawsuit
A 2 year old tripped while running and fell face first onto a sharp stick that penetrated deep into his mouth
He was feeling sick a few days later and the family requested a brain scan… healthcare staff said no
Steven ended up with a ruptured abscess on his brain and is now severely brain damaged
The family sued the hospital and got $7.1 million for pain and suffering, $4.1 million in economic damages for a total of 11.2 million
This is not a surgical case, but it shows how the family suffers. Even if they win a drastic amount of money, their son will never be the same. The heartbreak of a 2 year old who was running around and playing all of the time to now have brain damage and require specialized care for the rest of his life.
(Stewart, 2011)

7. What happened to the money?
¼ of the 1.4 million went to lawyers fees
$115,000 went towards the expert witnesses
$100,000 went towards private school for the disabled.
The mother had to quit her job, and they had to move into a larger home that could accommodate their son and then remodel it so he can maneuver
The child has had 23 surgeries and regular preventative appointments with specialist
He is currently covered under his dad’s insurance, but once he hits the age limit he will be taken off
When you look at the bigger picture, you realize that 11 million dollars will not go very far with medical conditions as severe as this child’s. Even though he is 21 right now, the family is already thinking about the cost of extended living facility when they are no longer able to care for them. He is lucky because the dad is still able to work and maintain the insurance. There are scenarios where the family is unable to maintain health insurance and they have to find help. A simple test could have possibly prevented this mishap(Stewart, 2011). Extended living facilities average around $3,300 a month which means $39,600 a year. For the patient who had the wrong side of the brain surgery and was placed in the extended living facility at 19, it will be costly. If he lives for an additional 30 years, it will cost $1.1 million. As medical costs continue to increase, it will probably be closer to $2-3 million.

8. What can we do to help as Nurses
Ensure that consent form is properly filled out and signed – and the patient understands what they are signing
Ensure that correct surgical site is marked
Ensure that “Time Out” is completed as soon as patient enters the operating room
Document everything that is completed on the patient.
Work as a team
Even though nurses are not completing the surgery, they are responsible for the patients safety. A circulating nurse should be knowledgeable of the procedure that is being completed on the patient. The nurse should be aware of the entire medical teams job, and watch for signs of mistakes being made. The circulating nurse is a key member of the team who advocates for the patient.

9. In the future…
In a perfect world, the number of surgical never events will be at zero
The Joint Commission requires accredited hospitals to follow the Universal Protocol
They are pushing each state to have a standardized checklist used in every acute care hospital by the end of 2013
They want to have “Safe Surgery” by 2015
Minnesota Safe Surgery Coalition started a campaign to eliminate the wrong site surgeries within 3 years. Before starting the campaign they would have a wrong site procedure every days. Now they have a wrong site procedure once every 30 days. Senior leadership will need to become more engaged, and be willing to provide training to ensure accuracy in procedures. Staff should be encouraged to speak up, and notify someone immediately if they see a mistake without repercussions. This is not something that will happen immediately, but with training, consistency and procedure, “never events” will occur less and less.
(Butcher. 2011)

10. Resources