Is poor communication to blame for surgical ‘never events?’

On Behalf of | Nov 12, 2016 | Surgical Errors

An article published this summer in JAMA Surgery journal reported that preventable, critical surgical errors are still occurring all over America’s hospital systems.

Research indicated that approximately .01 percent of surgeries result in foreign bodies like sponges being left behind in patients’ bodies. Perhaps even more worrisome, “wrong site” surgeries where surgeons operate on the wrong limb, side of the body or even patient, still happen about one time out of every 100,000 operations.

What is the reason for these egregious errors? Researchers believe that a lack of clear communication between medical personnel is one main cause of these “never events.”

As the lead researcher in the study commented, “Never events are, fortunately, very rare.” But that is of little consolation to the unfortunate patients to whom they did occur.

The study was done at the behest of the U.S. Veterans Affairs National Center for Patient Safety, in order “to evaluate the state of the evidence 10 years after the introduction of the Universal Protocol, a concerted effort to improve surgical safety,” she stated.

Researchers viewed data from 138 studies that dealt with one of three kinds of these “never events” — surgical fires, foreign objects left behind and wrong-site surgeries.

Frequencies varied dependent upon the surgery that was being performed, as well as the methods used for data collection. One study of opthalmology claims and reporting records, found .5 wrong-site surgeries for each 10,000 procedures performed. Yet another survey of eye surgeons found that strabismus, or “lazy eye” surgeries, produced as many as four wrong-site incidents per 10,000 operations.

Wrong-site surgeries seemed to have the closest ties to poor communication among medical staff personnel.

If you suffered an adverse event or worsened medical condition due to a medical error, you may have legal grounds to file a malpractice lawsuit.

Source: Live Science, “Major Surgical Mistakes Still Happen in the US,” Laura Geggel, accessed Oct. 28, 2016


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