never event

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never event2016-11-24T06:54:53+00:00

never event 


A term of art for an event which all knowledgeable professionals agree should never occur*.

*But does occur in surgery…at least 4000/year in the USA 

Examples, never events (NEs) Sponge, gauze or surgical instruments left behind during surgery; performing the wrong procedure; performing a procedure on the wrong site; performing a procedure on the wrong patient.

Profile of NE surgeons 35% are age 40 to 49; 62% had more than one never event

Consequences Death in 7%, permanent injury in 33%, temporary injury in 60%; malpractice judgements of ±$70 million/year. 

Synonym Catastrophic surgical error 

Reference Surgery, Dec 2012, M Makary, Johns Hopkins

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