The April issue of Surgery magazine reports a new patient safety study from John Hopkins University School of Medicine concerning medical mistakes in surgery. These “Never-Events” are things that should never happen and in some cases a never-event can trigger many additional issues. It becomes a tsunami of preventable situations including malpractice litigation. The study used data from the National Practitioner Data Bank which is a repository of medical malpractice claim data.  Both malpractice judgments and out-of-court settlements were included in the data search. The researchers using the data estimated that there are more than four thousand never-events in the United States each year.

To be more specific the study estimated “a surgeon in the United States leaves a foreign object such as a sponge or towel inside a patient’s body after an operation 39 times a week, performs the wrong procedure on a patient 20 times a week, and operates on the wrong body site 20 times a week.”

No wonder the JCAHO is so concerned about patient safety. The study also stated that the most likely surgeon to commit these errors would be between 40 and 49 years old. Older surgeons over 60 were less likely. It could be there are less surgeons over 60 doing less complicated cases attributing to the difference.

This study re-emphasizes that the implementation of “time outs” in surgery where all the parameters of the patient’s surgery are reviewed before the beginning of the case are vitally important. Many sites are requiring that the surgical site be outlined with magic marker. Counts of towels and sponges have been around a long time, but obviously need to be reconfirmed.

We are all responsible for the patient’s safety. Speak up if you see something that could be improved.