© Springer-Verlag London 2014
Philip F. Stahel and Cyril Mauffrey (eds.)Patient Safety in Surgery10.1007/978-1-4471-4369-7_22. Incidence of ‘Never Events’ and Common Complications
(1)
Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
(2)
Department of Orthopaedics, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA
Keywords
Never eventsCommon complicationsMedical errorsAdverse surgical outcomesPitfalls and Pearls
The concept of ‘never events’ is being utilized and defined differently by the National Quality Forum (NQF) and the Center for Medicare and Medicaid Services (CMS).
‘Never events’ according to the NQF definition are patient safety driven while the definition and types of CMS never events are financially driven.
The public may be confused and utilize the occurrence of a so-called post operative never event as defined by CMS against a surgeon or an institution.
NQF ‘never events’ such as wrong side surgery, medication errors and unintentionally retained foreign materials are still unacceptably high in our hospitals.
CMS ‘never events’ such as venous thromboembolic disease and or infections can be difficult to prevent and their occurrence may impact the financial viability of some institutions.
This latter point may put pressure on institutions and surgeons to carefully select their elective surgical candidate and exclude obese patients, uncontrolled diabetics and patients with poor dental hygiene (for Orthopaedic cases).
Outline of the Problem
Confusion persists with the definition of ‘never events’.
Historically, medical errors in surgery have been synonymous with and often are referred to as human errors. Although it was traditionally believed that human errors occur when a health care provider chooses an inappropriate method of care or improperly executes an appropriate procedure, medical errors have more recently, been attributed to communication, cognitive and affective aspects [1, 2]. Such errors are common and can contribute to a substantial number of adverse surgical outcomes.
The challenges lie in the definitions. Confusion persists in relation to the terminology of ‘never events’. In fact, two separate entities have utilized these same words in two different contexts. The National Quality Forum (NQF) defines never events as serious reportable events in healthcare. Out of a list of 28 events, the 5 first listed are surgically related and include Surgery performed on the wrong body part, the wrong patient, wrong surgery performed, unintended retention of foreign object and intraoperative or immediate postoperative death in an ASA class I patient. While these represent unacceptable errors, not all of the 28 listed events are preventable at all times. Centers for Medicare and Medicaid Services (CMS) utilized the identical terminology to define their “non reimbursable serious hospital-acquired conditions”. The list of these conditions includes deep-vein thrombosis (DVT) following a total knee or hip replacement and a surgical site infection following an orthopaedic procedure amongst others. As pointed out by Lembitz et al. [3] having two lists based on the distinct definitions by the NQF and CMS may create confusion in the public and possible future compensation seeking for events listed in the CMS as ‘never events’ (such as a DVT following a total knee replacement). While it is true that some surgical complications stem from poor planning, carelessness, or distracted medical professionals, others such as infection and thromboembolic disease can occur despite all precautions that surgical and medical professionals take to avoid them. This chapter will focus on the incidence of some of the surgically related ‘never events’ as defined by the NQF as well as the incidence of some of the common complications in surgery defined as ‘never events’ by CMS.
In-Hospital Mortality
During the 10 years period between 1999 and 2009 rates of death in surgery have declined among all age groups. Although comprehensive patient safety programs have been used with success to reduce in-hospital mortality [4], patient death following surgery still occurs. It is a known fact that any surgical procedure carries the risk of mortality; however more invasive procedures and higher risk patient populations (e.g. elderly, multiple comorbidities) carry a higher risk than others [5]. Mortality can occur secondary to a medical complication after surgery, a result of medication errors or overdoses, reactions to anesthesia, or procedural errors during the surgical procedure itself.
Medication Errors
Medication errors in general are common and affect an estimated 1.5 million Americans per year. In the UK, a recent study suggested that following the review of 688 medical charts, almost 50 % had medication errors [6]. Despite efforts to reduce the incidence of medication errors, adverse drug events (ADEs) continue to be costly for society and cause harm to out patients [7]. The multidisciplinary team approach to surgical care (including the pharmacist), together with the use of physician computer order entry systems (CPOE) has been an accepted strategy to limit ADEs; however, medication errors in surgery still persist. A recent survey quoted that only 50 % of the 160 health care professionals surveyed believed the CPOE reduced drug errors [7]. The ease of using computer systems is essential to reducing adverse drug events through a CPOE [8, 9]; health information technology (HIT) systems that are not user friendly may actually lead to technology induced medical errors [9]. Integrating pharmacists into the multidisciplinary team is beneficial in the reduction of medication errors; however, physicians in general and especially surgeons seldom listen to pharmacists’ recommendations [10]. In a recent study, of the 301 recommendations made by the pharmacist in the ER, less than 60 % were followed by the doctors; in addition, surgeons were significantly less likely to accept the pharmacist recommendation (51 %), compared to medical physicians (69 %) [10]. It seems that in order to reduce medication orders, a combined approach of a multidisciplinary team that includes a pharmacist, a user friendly computer physician order entry system, and surgeon’s willingness to hear suggestions on medication orders from the team is essential to reduce the incidence of medication errors.
NQF Surgical ‘Never Events’
Wrong Site Surgery
The ‘horror’ of wrong site surgery is far from over, despite a decade of global implementation of surgical safety checklists [11]. This type of ‘never event’ is far from being isolated to poor quality hospital or surgeons [12]. Using a systematic checklist, universal protocol, or “time-out” procedure reduces the chance of wrong site surgery; however, barriers to their implementation still exist [1, 13]. From the time a patient is indicated for surgery, there are many steps that occur prior to skin incision, and errors in each or any of these steps may lead to a wrong site surgery. Examples where errors can occur include booking of the procedure by the office staff, an error on the consent, error in reporting the correct site by radiology, poor communication between the surgeon and patient in the holding area, time pressures, changes in nursing staff shifts, time pressures of a surgeon using multiple rooms, improper marking of the patient in the holding area, not performing an adequate “time-out”, amongst others [1]. Even in the best of hands, wrong site surgery can occur because of cognitive, administrative, or procedural errors [1]. It is crucial that multiple checkpoints or “systems” be in place to prevent or recognize errors at each point of care.
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