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Researchers prove how human behavior leads to never events

As many Maryland residents might understand, never events are dangerous. According to the Agency for Healthcare Research and Quality's Patient Safety Network, the term "never event" was coined by the CEO of National Quality Forum in 2001 and related primarily to surgical errors that should have never occurred in the first place. In 2002, the NQF listed 27 never events and by 2011, the list contained 29 never events.

Recently, researchers from the Mayo Clinic identified 69 such never events from 1.5 million surgeries over a five-year period and detailed why those surgical errors occurred. In order to arrive at a conclusion, the researchers used a method that was used to investigate military plane crashes. The researchers used various aspects of human behavior to determine how such behavior led to those surgical errors. According to the study, there are 628 human factors involved in those surgical errors.

Researchers at the Mayo Clinic based their findings on 24 wrong procedures, 22 wrong-site surgeries, five wrong implants and 18 instances of objects being left inside a patient's body. All of those cases occurred at the Mayo Clinic and, thankfully, none were fatal. Interestingly, the report indicated that almost two-thirds of the never events occurred during minor surgical procedures, such as endoscopy, anesthetic blocks, line placements, interventional radiology procedures and skin or soft tissue procedures.

To investigate those surgical errors, the Mayo Clinic researchers employed a technique that was used by the military to investigate military aviation accidents. They categorized the errors into four groups, which included preconditions for action, unsafe actions, oversight and supervisory factors and organizational influences. Based on this collection of factors, the researchers were able to identify the 628 human factors that may often contribute to surgical errors.

With so much research being conducted in patient safety, Maryland residents may expect health care to be safer in the future than it is at present. However, the possibility of an odd incident of a never event cannot be ruled out completely. Therefore, in such a situation, it may be wise to seek legal counsel and investigate if the surgical error could have been prevented if the responsible people had been more attentive toward the patient in addition to following the rules and regulations.

Source: MayoClinic.org, "How Does Human Behavior Lead to Surgical Errors? Mayo Clinic Researchers Count the Ways," Sharon Theimer, June 2, 2015

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