Surgical “never events” continue to occur

Surgical “never events” continue to occur despite the Joint Commission’s universal protocol that attempts to prevent them, according to a study in the Archives of Surgery.

Key findings from the study:

  • Significant harm was inflicted in 20% of wrong-patient procedures and 35% of wrong-site procedures; one patient died secondary to a wrong-site procedure (0.9%);
  • The main root causes leading to wrong-patient procedures were errors in diagnosis (56.0%) and errors in communication (100%);
  • Wrong-site errors were related to errors in judgment (85.0%) and the lack of performing a "time-out" (72.0%);
  • Nonsurgical specialties were involved in the cause of wrong-patient procedures and contributed equally with surgical disciplines to adverse outcome related to wrong-site occurrences.

The authors call for expanding the Universal Protocol to nonsurgical specialties and to promote a zero-tolerance philosophy for these preventable incidents.

(Sources: Archives of Surgery,, October, 2010; AHA News Now,, October 18, 2010)