The Surgical Never Errors. Post Number 1

Safety Blog Posts: Blog post number 1

Safety, Surgeons, Staff, Systems and a Culture of Safety

Your concerns as a patient should be to understand patient safety for the benefit of yourself, your family, and your loved ones.
One of my goals is to make you more safety sophisticated so that as a patient you gain skills for recognizing safe and unsafe situations and systems. Your concerns then have to do with recognizing “Culture of Safety“.

Safety or lack of it depends on Surgeons, Staff, Systems working safely with active communication taking place. in a safe system an error can be put in motion by one of the care providers but stopped by another health care provider (HCP) before it occurs and injures a patient .

I am a surgeon by trade and surgical safety comes to my mind first although surgical patients can be harmed by medical errors such as medication administration errors. Let’s get started with an area that need not be confusing but has become a bit confusing for all of us.

As we discuss problems with surgical safety of patients be mindful that even though the surgeon may execute an error the “never” errors the patients have other HCP’s who may participate in causing the error (this means a system error may be operational)

What are never errors in surgery?

Originally the errors of doing the wrong operation on the correct patient, operating on the incorrect body part of the patient (wrong side, site), or operating on the wrong patient.
These never errors were first described by Ken Kizer, MD. The information that follows immediately is taken from the entry at another web site. I suggest that you click on the link after you finish reading this post.

AHRQ Patient Safety Network

Background

“The term “Never Event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The NQF initially defined 27 such events in 2002. The list has been revised since then, most recently in 2011, and now consists of 29 events grouped into 6 categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal.”

What can we learn from this excerpt? Basically that when we discuss never errors that today we have to specify which area we are discussing. I am choosing to start with the area with which I am most familiar namely the surgical never errors; errors of doing the wrong operation on the correct patient, operating on the incorrect body part of the patient (wrong side, site), or operating on the wrong patient. Many surgical discussions include unintentionally leaving objects inside of a patient with the side, site, patient with this group of errors. I will not include this type of error.