Doctors call them “never events” because they are never supposed to happen. In surgery this term applies to things like leaving an instrument or a sponge inside the patient, operating on the wrong side or part of the body, or doing the wrong operation.
In the 21st century, modern hospitals should have systems in place to prevent such mistakes. They are always avoidable. There is absolutely no excuse for a surgeon operating on the wrong body part or leaving behind a six-inch stainless steel tool in someone’s abdomen. And yet a new study published in the journal Surgery (online Dec. 17, 2012) titled “Surgical Never Events in the United States” reports that these mistakes remain distressingly common.
According to the authors, roughly 4,000 never events occur each year in U.S. hospitals. Roughly 40 times a week a sponge or a towel is left behind inside a patient. About 20 times a week the wrong side or the wrong body part is operated on. And about the same number of times the wrong operation is performed.
Here is how the researchers came up with these numbers. In 1986 Congress passed legislation requiring records of all malpractice payments. Whenever a malpractice claim is paid or settled (even if it is a hush-hush out-of-court deal) it has to be recorded in the National Practitioner Data Bank (NPDB). The investigators at Johns Hopkins “identified 9,744 paid malpractice reports with surgical never events between September 1990 and September 2010.” They then went on to extrapolate:

“Based on the number of paid claims we identified in the NPDB and the literature estimates of surgical adverse events resulting in paid claims, we estimated that 4,082 surgical never claims occur each year in the United States (retained foreign body = 2,024/ year; wrong-procedure surgery = 1,020/year; wrong-site surgery = 1,005/year; wrong-patient surgery = 33/year).”

These numbers may represent a substantial underestimation of the actual number of serious surgical mistakes made annually. Keep in mind that these researchers analyzed malpractice claims. That means a lawyer had to take on the case and move it through the court system. Many “never events” go unrecognized by patients. They may live with chronic discomfort not realizing that a sponge was left behind during surgery. Others may not be able to convince an attorney to take their case. Still other cases are settled without getting into the legal system. There is no mandatory reporting system in this country when a surgeon makes a bad error during an operation.
Consider this: A 5-year study of surgical adverse events at three surgical centers revealed that 130 patients were harmed. Yet only 12% of the patients who were injured by the surgery itself received a payment (Annals of Surgery, June, 2003). These investigators found that over two-thirds of patients who are injured because of an adverse surgical event never sue. It is entirely possible that the number of serious surgical mistakes is much higher than anyone imagines.
When someone has the wrong leg amputated or a routine X-ray reveals a metal clamp left behind, it is dramatic and horrifying. Such mistakes make headlines, but they are only the tip of the iceberg. In our book, Top Screwups Doctors Make and How to Avoid Them, we discovered that hundreds of thousands of patients die each year because of health care harm (iatrogenesis). Here are some statistics to consider:
• Fatal Hospital Acquired Infections = More than 100,000 deaths/yr.
• Fatal Adverse Drug Events in hospitals = 106,000/yr.
• Fatal Adverse Drug Events in nursing homes = 93,000/yr.
• Misdiagnosis leading to death in hospitals = 100,000/yr.
• Pressure ulcers (bed sores) leading to death 60,000/yr.

These stats do not include venous thromboembolisms (blood clots in veins) that can lead to pulmonary embolisms [blood clots in the lungs] and death. They do not take into account excessive radiation which may indirectly lead to thousands of deaths annually from cancer (Archives of Internal Medicine, Dec. 14, 2009).
Then there are the people who die from adverse drug events at home. When a person has a heart attack or a stroke after taking an arthritis drug like diclofenac, it is rarely, if ever, attributed to the prescribed medication. No one has a clue how many people die from such complications of drug treatment.
The bottom line is that the number of people who die from health care harm is roughly comparable to the number of people who die from heart attacks or cancer each year. And yet there is no outrage and little effort to solve the problem. There is no “war on errors” like the war on cancer.
Where does that leave you, the patient? In essence, you are on your own. Expect mistakes to happen. Before you agree to surgery here are the questions to ask:
• What exactly will be done?
• Why has it been recommended?
• Are there any alternatives to this surgery?
• What kind of anesthesia will be used and what are the side effects? Are there any alternatives that are safer?
• Is there is a checklist system in place in the O.R. before every surgical procedure?
• Will the surgeon sign the side of the body and the body part that is to be operated on and can you verify it is correct before undergoing anesthesia?

If you would like a more in-depth understanding of the kinds of medical mishaps that commonly occur every day in the U.S. and around the world, you may find our book, Top Screwups Doctors Make and How to Avoid Them, of value. We will help you make your next doctor visit or hospital stay safer.
We provide top 10 tips for:

• Stopping screwups in hospitals
• Avoiding diagnostic disasters
• Preventing dangerous drug interactions or adverse drug events
• Sidestepping pharmacy errors
• Avoiding generic drug problems
• Preventing medical problems for people over 65

You can learn more by clicking on this link. The image of the surgical instrument left behind can be found at this link.
And please share your story below. We would like to know if you ever experienced an error and a bad reaction. How did you assert yourself prior to anesthesia or surgery? We would like to learn about successes so that others can benefit from your interactions with the health care system.

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  1. JS
    Reply

    Both my grandfather and my father had hallucinations after surgery, whether due to anesthesia or pain meds, I don’t know, but we had to have someone stay with them round the clock. My grandfather suffered a broken cheekbone trying to get out of bed, swearing he was being attacked. My dad ripped out his catheter and attacked a nurse. Neither one of them was violent when in their right minds.
    Fortunately, they both returned to normal after they were off the meds and back home. Even being prepared, as we were after the first incident, it was awful to watch a loved one go through that.
    My dad had hallucinations in Hospice as well, due to Ativan. We requested no more Ativan, and the Hospice doctor told us sometimes we had to do things we didn’t want to do. I asked him point blank away from my mom, and he said, yes, they were still giving Dad Ativan, despite Dad’s and our wishes.
    Fortunately, it was put in his chart, and the nurses refused to give it. Dad was able to spend much more coherent time with us than the doctor expected, thanks to those nurses.

  2. Donna S.
    Reply

    During a hysterectomy in ’04, the doc “accidentally nipped a vessel” and I lost “1000 units of blood” — he told me this when he came in after the surgery to speak to my husband and me. As a result of the blood loss, I experienced permanent vision loss when the optic nerve in my left eye collapsed, and severe anemia for weeks afterward. A year or so later I began to experience chronic UTIs which I’d never had a problem with at all before. In ’08, after many courses of antibiotics for UTIs, a urologist looked into my bladder and found what appeared to be three growths. He operated to biopsy and/or remove the “tumors” but instead found 3 metal staples embedded in the bladder wall.
    They’d been collecting bacteria and were pretty gross. The urologist/surgeon removed them and I became symptom free — no UTIs for awhile. The staples must’ve been left by the gyno in ’04. This Nov. after another couple of years of UTI’s and many more courses of antibiotics, I passed a stone after much vaginal bleeding. The urologist again found a metal staple had apparently migrated to my bladder wall, and a stone had formed in my bladder.
    Know that my records from the gyno do not mention the nipped vessel, the blood loss, vision loss or anemia. I also got a copy of the “surgeon’s notes” since I’d been told that everyone in the operating room during my surgery had to sign off on those notes, so they would contain all that happened — and they did not tell all, although everyone apparently did sign off on them. Once again I’m now symptom free for several weeks in terms of UTIs, however I have no idea how many more staples I have inside — or where they are…
    As a cancer survivor, I’ve had all kinds of scans and xrays during this time period and the staples did not show up on any of them. I’m at a loss re what to do. The one time I spoke to a lawyer about the irreparable vision loss, he felt I had evidence for a good case, but I didn’t have all the money needed up front for hiring experts to testify, paying the lawyer and his staff, etc.
    I don’t care about making a lot of money (although no doubt his mistake created many problems), but the total lack of accountability makes me mad/sick. How can he continue to practice and never acknowledge his mistake and how many more mistakes has he been allowed to make with no consequences?

  3. JS
    Reply

    If you want to read a personal story about “death by hospital,” backed up by research and statistics, please look for the book “The Last Collaboration” by poet/advocate Martha Deed with her daughter, poet and artist Millie Niss. It will break your heart.

  4. CM
    Reply

    I had a back operation recently and as a result of the anesthesia, I had hallucinations afterward.
    Took me a month to get my brain back to normal. would ask for a “cup of coffee” and it would come out as “a cup of carrots.”
    Thought is was just me but have talked to people since and they have told similar stories. What are they using in anesthesia now a days???

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