Wrong procedure, wrong side/site, wrong implant, retained foreign object: big problem. No patient should ever have to undergo these types of events, and they are therefore called never events. However, these events do occur and when they do they not only jeopardize patient safety but they also breach the trust between patient and practitioner, have financial implications, and reflect negatively on the entire health care system.
The good news is never events are rare. But when you consider that, in theory, the rate of never events should be one in infinitely, the nationally reported rate of 1 in every 12,000 procedures is still too many. So why do these events still happen after decades of work to prevent them? Well, it turns out while there isn’t usually one human to blame; the causes are very, well, human.
Over the last few decades, researchers have identified that things such as system breakdowns, technical errors, communication failures, and most commonly a combination of all these things (Swiss cheese anyone?) contribute to why never events occur. But despite this research and the subsequent implementation of OR checklists, briefings, barcode systems, and safety counts, these events continue to occur. While the current systems and processes are moving us in the right direction, it is important that we take a closer look into why these events continue to occur.
In an article recently published in Surgery, we set out to better understand what factors were contributing to never events. Using a model initially developed to study aviation disasters, we set out to identify the environmental, organizational and individual characteristics that play a role. It turns out that there was not one person, machine, or system to blame. In fact, while it took us 22,000 procedures to identify an event we did identify 69 events and 628 human factors that contributed to these errors. This means that approximately nine human factors contributed to each event.
To better understand this very human problem, we grouped these factors into 4 categories: unsafe actions (Did a team member not complete a required checklist?), preconditions for actions (Was the surgeon tired?), oversight/supervisory factors (Was their inadequate supervision?) and organizational influences (Is there an unsafe culture?).
As it turns out, oversight/supervisory factors and organizational influences rarely played a role in these events. Unsafe actions (also known as the error itself) played an important role in most of the events. However, the unsafe act rarely involved breaking or bending a rule (not following a required checklist) and usually involved things like a confirmation bias. (“There can’t be a sponge left behind because I checked.”) While the unsafe actions are important to recognize they often are more difficult to fix. This is where preconditions to actions come into play.
Preconditions are the conditions that lead up to the error. When we looked into the preconditions, we found, to our surprise, that these never events often occur in very minor non-emergent procedures. In addition, patient factors like obesity were rarely cited as contributing. What was often cited was channeled attention on a single issue, overconfidence, and inadequate communication or what we collectively call, cognitive factors. One’s cognitive capacity on any given day can be altered by fatigue, time constraints, and team composition. To prevent these preconditions from becoming errors, we must not only identify them but also prevent them. One way to do this is to decrease cognitive workload is by engaging other team members (or even computer systems) to share the load. Preventing these preconditions from occurring is the real key to preventing an error and improving patient safety.
So, how do we eliminate never events from our health care system? Well, there is no magic bullet (or pill). But what we do know is that in addition to systems approaches and efforts to improve communication, we need to better utilize the teams and technology so that never events will occur, well, never.
Cornelius Thiels is a general surgery resident who blogs at MBlog Mayo Clinic.
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