Six Procedures Hospitals Should Implement to Prevent Surgical Never Events

A patient was admitted for surgery to have an adrenal gland and associated mass removed. The surgeon called the patient six days later to say that the patient would need a second surgery because "he did not get everything." According to the patient's lawsuit, the surgeon removed the patient's healthy right kidney instead of the gland and mass.



The patient alleges she now suffers from incurable, progressive kidney disease in her remaining kidney, as well as pain, fatigue and, depression.


See: ABC15 Arizona, Iowa woman says surgeon wrongly removed her kidney during botched surgery.


What can hospitals do to prevent the occurrence of “never events” like surgery on the wrong body site or using a wrong procedure?


Hospital risk managers must implement procedures to prevent what is estimated to be the occurrence of over 4,000 surgical never events per year, events that never should happen. Large settlements and jury verdicts have resulted.


The following are six procedures that hospitals should consider implementing to prevent surgical never events from ever happening:


Involve the patient in their own care, including the marking of the intended operative site


Require the use of pre and post-surgery checklists confirming the correct patient, the correct site, the correct procedure


Establish effective communication methods in the operating room such as consistent terminology for methods and equipment


Implement a “time out” period during surgery to confirm aspects of the operation such as the correct patient, the correct site, the correct procedure


Eliminate distractions in the operating room including unnecessary interruptions


Audit to verify compliance with and effectiveness of implemented risk policies and procedures


For in-depth law and medical information see:


Medical Risk Law: Surgical Misidentification: Wrong Site, Wrong Procedure, Wrong Patient


Expert Analysis in the above Medical Risk Law, the monthly report on specific medical litigation topics:


What Steps Can Surgeons and Hospitals Take to Reduce the Risks of Surgical Misidentification?
Maggie M. Finkelstein, JD: Shareholder, Stevens & Lee


How Can Checklist Protocols Reduce Surgical Never Events and Increase Patient Safety?
Peter Pronovost, M.D., Ph.D., FCCM: Senior Vice President for Patient Safety and Quality, Johns Hopkins Medicine; Recipient, MacArthur Foundation “Genius Grant”


For Litigation and Discovery Documents, Checklists, Strategies, and other materials on this and other medical litigation, see Medical Risk Law.


For more Guidance & Analysis get Medical Risk Law