Performance Health Partners
Preventing never events in healthcare is a critical factor for improving safety, specifically surgical safety, as these errors can have devastating consequences for patients. Incident reporting solutions play a pivotal role in identifying, analyzing, and addressing the root causes of these preventable events, stopping them from occurring all together.This blog post delves into what never events are, their consequences, and how incident reporting solutions can enhance surgical safety to prevent never events from occurring in the first place.
What Are Never Events in Healthcare?
Never events in healthcare are severe, clearly identifiable, and preventable medical errors that the National Quality Forum (NQF) describes as “particularly shocking.” Their occurrence signals significant issues with the safety and credibility of a healthcare organization.
The current never event list consists of 29 “serious reportable events” grouped into seven categories including patient protection events, produce or device events, environmental events, radiologic events, and surgical or procedural events.
Surgical never events are among the most severe types of medical errors, often leading to catastrophic outcomes. Common types of surgical never events include:
- Wrong-site surgery, where a procedure is performed on the wrong part of the body
- Surgery or other invasive procedure performed on the wrong patient
- Unintended retention of a foreign object, such as a surgical instrument or sponge, left inside a patient after surgery
- Wrong surgical or other invasive procedure performed on a patient
- Intraoperative or immediately post-operative/post-procedure death in an American Society of Anesthesiologists Class I patient
Since these types of events are entirely preventable and also have severe consequences, they are deemed “never events” because they should never occur under any circumstances.
In the context of surgical safety, the consequences of never events on patients are profound, but they also have a grave impact on healthcare organizations. These events result in higher operating costs, reputational damage, and a decrease in trust with patients.
In fact, a recent study concluded that “never events” lead to significant increases in Medicare hospital payments, with costs ranging from an average of $700 extra per case for treating decubitus ulcers to $9,000 per case for treating postoperative sepsis. Furthermore, a review of 18 types of medical events determined that medical errors may result in 2.4 million additional hospital days, $9.3 billion in extra charges across all payers, and 32,600 deaths.
The State of Surgical Safety: Never Events in Healthcare
Last year, the National Health Service (NHS) found that 384 never events occurred across England between April 2022 and March 2023, with monthly instances reaching as high as 43. This marks an increase from the previous year’s figures.
Furthermore, the Joint Commission’s Sentinel Event Data 2023 Annual Review shows the persistence of two significant types of surgical errors in the United States: wrong surgery and unintended retention of a foreign object.
Both wrong surgery and unintended retention increased from 2022 to 2023—wrong surgery by 26% and unintended retention of a foreign object by 11%.
It's crucial to acknowledge that never events, while severe, are uncommon. The majority of clinicians diligently work to ensure procedures are conducted without complications.
However, the ongoing challenges in our ever-evolving healthcare landscape cannot be ignored. One must consider whether the frequency of never events could rise from overworked or insufficiently trained staff operating under unreasonable time and resource constraints. After all, research shows that when the healthcare system is overstretched, the likelihood of errors increases.
These figures demonstrate the need for healthcare teams to consider procedural and organizational modifications, as well as technological systems that could reduce the frequency of these “never events.”
As such, the importance of implementing effective incident reporting solutions cannot be overstated. Incident reporting software allows healthcare organizations to easily track, identify, and analyze the root causes of never events. With this knowledge, the organization can then address these issues internally, learn from the experience, and take action to prevent future incidences from occurring.
Current Barriers to Effective Incident Reporting
Despite the critical importance of incident reporting in preventing surgical never events, there are several barriers that prevent effective reporting in many healthcare settings. Some of the primary challenges include:
- Fear of blame or retribution
- Lack of a culture of safety
- Lack of awareness of reporting processes
- Inefficient, outdated, and/or complicated incident reporting processes
Many healthcare providers may be reluctant to report errors or near misses, fearing that doing so could result in disciplinary action, damage to their professional reputation, or even legal consequences. The lack of a supportive, nonpunitive culture of safety reduces the willingness of staff to dedicate their time to the incident reporting process, leading to underreporting and the pervasiveness of never events without fully understanding their causes.
Additionally, the role of a robust culture of safety within a healthcare organization cannot be overstated, as it greatly impacts the reporting behaviors of healthcare staff. In organizations where a culture of open communication and transparency are not prioritized, healthcare workers may feel that their reports will not be taken seriously or lead to meaningful change.
As systemic failures are often the culprit for many never events, healthcare organizations should prioritize not only encouraging reporting and open communication but upholding their commitment to patient safety by taking action to address errors. When healthcare staff see that their reporting leads to actionable changes, they feel valued and are motivated to continue their reporting.
In organizations where a culture of safety is emphasized, reporting is encouraged and valued, and when reporting leads to actionable changes, incident reporting solutions are more likely to be effective.
Another significant barrier is the cumbersome nature of many traditional incident reporting solutions. Complex, time-consuming paper-based reporting systems can discourage healthcare professionals from documenting incidents, especially in fast-paced surgical environments where time is critical. In addition, paper-based reporting practices are vulnerable to errors and inconsistencies due to the lack of standardization.
When reporting processes are not user-friendly, the likelihood of underreporting increases, leading to missed opportunities for learning and improvement.
“The root causes of avoidable patient harm events are most often systemic failures,” said Dora Hughes, MD, MPH, Chief Medical Officer and Acting Director of the Center for Clinical Standards and Quality (CCSQ) for the Centers for Medicare & Medicaid Services (CMS) in a press release discussing the prevention of never events in healthcare. “Reducing preventable harm to patients starts with having accurate data so that common, recurring systemic problems contributing to harm events can be quickly identified and addressed.”
Key Features of an Effective Incident Reporting System
When considering the benefits of an incident reporting system on surgical safety and the prevention of never events, healthcare organizations must ensure that their solution is able to meet these goals successfully. Effective incident reporting solutions should include the following key features:
- Anonymity and Confidentiality: Ensuring that reports can be made anonymously is crucial in encouraging healthcare providers to report incidents without fear of blame or retribution. Confidentiality protects the identity of reporters to promote a culture of safety that centralizes on solving errors, rather than punishing those who report them.
- Simplicity and accessibility: The reporting process should be simple, intuitive, and easily accessible to all members of the organization. Minimal, user-friendly interfaces and mobile or tablet-enabled reporting options encourage reporting compared to lengthy and complicated paper or spreadsheet processes.
- Integration with existing hospital information systems: Incident reporting solutions should seamlessly integrate with existing hospital information systems to ensure that data is captured accurately and can be easily analyzed and acted upon. A detailed implementation plan, access to support, and training for healthcare staff can ensure that the existing system and the implementation of the new system aligns with the needs of the organization.
- Real-time feedback and communication channels: Providing real-time feedback, along with clear communication channels for follow-up are essential to keeping the reporting process effective and useful. Real-time data access allows management and administration to ensure that reports are not only immediately acknowledged but also lead to actionable improvements. In addition, this can improve morale amongst healthcare providers, assuring them that their reporting efforts are valued by the healthcare organization.
Other Innovations Improving Surgical Safety
The rise of new technologies has brought significant advancements to healthcare, particularly in the surgical field, for the prevention and reporting of never events.
Radio frequency identification (RFID) technology is one such innovation, allowing for the precise tracking of surgical instruments and sponges during procedures. This technology significantly reduces the risk of retained surgical items by attaching small RFID tags to each sponge. During surgery, antennas emit radio waves that are absorbed by the tags, which then send back a unique signal. This allows the system to monitor and locate all tagged sponges in real-time, alert the medical team, and allow them to intervene.
A study by the Journal of Surgical Research found that RFID technology was successful in detecting and retrieving 100% of the sponges used in their study, revealing that this new RFID technology could pave the way for reliable sponge tracking and correct detection of retained objects.
Another type of technological innovation aiding in the prevention of never events is machine learning—a type of computer technology that helps machines learn from data and make predictions. After feeding the computer more data over time, the computer analyzes patterns and learns to make predictions. The more data it sees, the better it gets at recognizing data on its own.
This technology can be used in healthcare to track, identify, and predict errors that might be missed by human intervention alone. For example, according to a study by Patient Safety in Surgery, machine learning was used to reveal unknown contributing factors to the occurrence or prevention of surgical item retention and better understand why and how this never event occurs. The results found that a discrepancy in the surgical count was a contributing factor to never events, while a fascia closure after a correct surgical count or a staff’s agreement to time out were protective factors for the prevention of never events.
The predictive capability of machine learning enables healthcare providers to take proactive measures to prevent errors before they occur, further enhancing surgical safety.
Preventing Never Events: Best Practices for Healthcare Organizations & Surgical Teams
Implementation of the following best practices is crucial for healthcare organizations to ensure surgical safety and prevent avoidable never events.
Prioritize Communication Among Teams
One of the most effective strategies for preventing never events in healthcare is to enhance communication among surgical teams. In fact, increasing evidence indicates that communication failures among team members are frequently at the root of medical errors and adverse events.
The Joint Commission reported that in the United States, poor communication was identified as a primary cause in nearly 70% of the adverse events reported to them over a ten year period.
Moreover, it's clear that operating teams acknowledge the impact of these breakdowns on safety and effectiveness, as two-thirds of nurses and physicians identified improved team communication as the key factor in preventing never events, and enhancing safety and efficiency in the operating room.
Encouraging an environment where open communication is valued and seen as an opportunity for learning and improvement is essential for promoting a culture of safety. Leadership should model these behaviors and actively engage in open dialogue with healthcare staff to set the standard for the entire organization.
Invest In Effective Incident Reporting Solutions
Healthcare organizations should invest in digital incident reporting solutions that make it easy for healthcare professionals to document incidents. By implementing systems that provide anonymity, confidentiality, and real-time feedback, the reporting process is not only streamlined but encouraged due to its efficiency in contrast to paper reporting processes.
Additionally, effective incident reporting solutions allow for the tracking of root causes in the case of surgical never events. After a never event or near miss, performing a thorough root cause analysis to identify the underlying factors that contributed to the incident and using the findings to implement targeted interventions can prevent similar events in the future.
Foster a Culture of Safety
Building a culture of safety within the healthcare organization, and specifically in surgical teams, is essential for ensuring high-quality care so that errors are less likely to occur. All members of the surgical team should be encouraged to speak up about potential risks and feel empowered to take proactive measures to prevent harm. This culture should start at the administrative level, with leadership clearly and openly promoting safety as a core value.
This can be achieved by involving surgical staff in the development and implementation of surgical safety protocols, encouraging them to share their own ideas, and providing them with the tools and training needed to identify and address risks. This culture of safety becomes the foundation upon which effective incident reporting solutions are built, ensuring that all incidents, from never events to near misses, are identified and analyzed to prevent their occurrence and encourage surgical safety across the organization as a whole.
Final Thoughts
Preventing surgical never events in healthcare is a critical priority, given the severe consequences these incidents can have on patients, providers, and the broader healthcare system. Effective incident reporting solutions play a vital role in improving surgical safety by enabling healthcare professionals to document and analyze errors to prevent them from occurring in the future.
“By updating the criteria we use to classify and report on events that harm patients across healthcare systems and care settings, we can harness improved data to accelerate research, development, and implementation of policies and technologies to fuel much-needed improvements in patient safety in the United States,” said Robert Otto Valdez, PhD, MHSA, Director of the Agency for Healthcare Research and Quality (AHRQ).
Overcoming the barriers to effective reporting, leveraging the latest technological innovations, and implementing incident reporting solutions can create safer surgical environments and reduce the prevalence of never events in healthcare. However, continuous commitment to fostering a culture of safety, where incident reporting is viewed not as punitive but as crucial for improvement, is necessary to maintain surgical safety procedures and improve overall patient safety and outcomes.