1. “Never Events” in Surgery Stephen D. Cassivi, MD MSc FRCSC FACS Professor of Surgery Vice Chair – Department of Surgery cassivi.stephen@mayo.edu

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

3. Audience Response Questions Never Events in Surgery

4. 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

5. 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

6. 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

7. 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

8. 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;465-472. Never Events in Surgery

9. 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;465-472. Never Events in Surgery

10. 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

11. “Never Events” in Surgery Stephen D. Cassivi, MD MSc FRCSC FACS Professor of Surgery Vice Chair – Department of Surgery cassivi.stephen@mayo.edu

12. “Never Events”

14. “The defense strenuously objects.”

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

16. 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

17. 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.

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

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

20. 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)

21. 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

22. “Never Events”

23. “Never Events” Steps to take

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

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

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

27. “Never Events” Best Practices

28. “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

31. “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

32. cassivi.stephen@mayo.edu