Frequency of never events
Although most never events are rare, these safety incidents can have significant effects on patients and hospitals. Here are three statistics on the frequency of never events, compiled by the Agency for Healthcare Research and Quality:
1. More than 4,000 surgical never events occur each year in the U.S., according to a 2013 study.
2. The average hospital may experience a wrong-site surgery case once every 5 to 10 years, according to a 2006 study.
3. The majority — 71 percent — of never events reported to The Joint Commission between 1995 and 2015 were fatal.
Most common never events
In March 2018, The Joint Commission updated its sentinel event statistics for 2017. The organization reviewed 805 reports of sentinel events reported during the 2016-17 calendar year. Here are the 10 most frequently reported sentinel events for 2017, according to The Joint Commission:
1. Unintended retention of a foreign body — 116 reported 2. Fall — 114 3. Wrong-patient, wrong-site, wrong-procedure — 95 4. Suicide — 89 5. Delay in treatment — 66 6. Other unanticipated event, such as asphyxiation, burn, choking on food, drowning or being found unresponsive — 60 7. Criminal event — 37 8. Medication error — 32 9. Operative/postoperative complication — 19 10. Self-inflicted injury — 18
4 things that worry me about these statistics
1. Under-reporting is a problem - therefore we don't know the true scope of the problem.
2. Under-reporting tells me that most institutions are still hiding their mistakes - thus there isn't enough transparency and we'll never reach the levels of safety that are possible.
3. Even if these numbers were accurate (and I don't think they are), too many patients are being harmed.
4. Most of these are preventable and I worry about why we are not preventing them.
5. Most of these already have an evidenced-based protocol proven to prevent them. Why are these protocols not being used? Are physicians and staff not holding each other accountable to use them?
6. We've known about these problems for years. Why isn't more progress being made?