Despite Clear Rules, Serious Injury and Death During Surgery Still Happens
Surgeons operating on the wrong patient or the wrong part of your body? These careless medical problems are called “Never Events” because they are so shockingly avoidable that most doctors say they should “never” happen in the first place. Yet they do happen. Even though the medical profession has developed a “universal protocol” for doctors to follow prior to surgery and performing other key medical procedures, health professionals continue to cause injury and even death to patients in situations where such injury is entirely preventable. Listed below are examples of medical events identified by the National Quality Forum that should never occur and, if they do, require immediate investigation. The NQF is a nonprofit organization dedicated to improving American healthcare quality.
Surgical events
Surgery performed on the wrong body part
Surgery performed on the wrong patient
Wrong surgical procedure performed on a patient
Product or device events
Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the hospital
Patient protection events
Infant discharged to the wrong person
Patient death or serious disability associated with patient elopement (disappearance)
Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a health care facility
Care management events
Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)
Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility
Stage 3 or 4 pressure ulcers acquired after admission to a health care facility (for example, nursing home)
Environmental events
Patient death or serious disability associated with an electric shock while being cared for in a health care facility (for example, psychiatric institution)
Patient death or serious disability associated with a fall while being cared for in a health care facility (for example, nursing home)
Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility (for example, psychiatric institution)
Criminal events
Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider
Abduction of a patient of any age
Sexual assault on a patient within or on the grounds of the health care facility
Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the health care facility