It’s every patient’s worst nightmare – your surgeon makes a mistake, putting you in danger. The doctor performs the wrong operation or operates on the wrong body part. Or your doctor leaves something inside your body, gives you the wrong medication, or leaves in the middle of your procedure! Learn more about these surgical dangers to reduce your risk of potentially serious problems.
Surgical dangers: Never Events.
Some surgical dangers are called Never Events – categorized as serious and costly errors that are largely preventable and therefore should never happen.
What is a surgical Never Event?
According to a 2016 report by the National Quality Forum List of Serious Reportable Events, surgical Never Events are as follows:
How common are Never Events?
One study of malpractice settlements estimates that there were over 80,000 Never Events in US hospitals in 20 years (1990-2010). The authors evaluated data from paid settlements, only counting cases in which a patient successfully received a settlement payment.
Since not all harmed patients file malpractice claims, and not all who file a claim receive a settlement, it is logical to assume that there are likely many more of these events occurring every year.
Furthermore, these researchers estimate that in the US, surgeons, as a group:
- Leave a foreign object (sponge, etc.) inside a patient’s body 39 times/week.
- Perform the wrong procedure 20 times/week.
- Operate on the wrong body part 20 times/week.
Additionally, a study examined the frequency of wrong-site surgeries at Pennsylvania hospitals between 2015-2019. Researchers found that there was an average of 1.42 wrong-site surgery events per week in Pennsylvania. Furthermore, 76% of these events contributed to, or caused, temporary or permanent patient harm. Although this review only included Pennsylvania hospitals, I think we can assume that hospitals in other states have similar rates of these types of events.
Although it’s impossible to know the exact number of surgical Never Events, when it happens to you or a loved one it can be devastating.
How dangerous are surgical Never Events?
Fortunately, the effects of these surgical mistakes are generally not fatal. However, they did find that patients frequently suffer harm:
- Death occurred in 6.6% of the cases.
- Permanent injury occurred in 32.9% of the cases.
- Temporary injury occurred in 59.2% of the cases.
How can doctors and hospitals avoid Never Events?
Experts believe that closely monitoring Never Events will help in the development of effective ways to eliminate them. Additionally, creating an environment that encourages accurate reporting will move the efforts forward.
Although there is plenty of room for improvement, many, but by no means all, hospitals have programs in place to reduce the risk of these types of mistakes. Steps taken include:
- Using “timeouts” in the OR to make sure the scheduled surgery is the right surgery for the right patient.
- Marking the intended surgical site with indelible ink.
- Creating procedures for counting sponges and other surgical tools that staff might leave inside a patient.
- Using safety checklists.
- Using barcode scanners on all materials to allow precise counts.
What can you do to reduce your risk of Never Events?
I suggest the following steps to reduce your risk:
- Before you schedule a surgery, speak with the surgeon to find out specifically what steps he/she will take to avoid these Never Events. Ask how they keep track of surgical tools and supplies, and how they make sure they are performing the right procedure on the right body part for the right patient.
- Before signing any paperwork, read it carefully to make sure it indicates the correct procedure, on the correct body part.
- Use indelible marker to note your surgical location on your body. It might seem odd to write “this knee” or “NO” on your body, but it’s better than having surgery on the wrong body part.
- Additionally, before your surgery begins, the team should discuss the upcoming procedure with you (or your family member) and mark your body to indicate the designated location for the procedure. Make sure this is accurate before you go under anesthesia.
- Research your surgeon and hospital. Find out if your surgeon has been involved in a malpractice suit. See the ZaggoCare Resource Center for links to websites where you can evaluate doctors and hospitals. Additionally, read What’s Your Hospital’s Safety Record? Is Your Hospital Safe? and Is Your Hospital Safe? Are Programs in Place to Avoid Dangerous “Never Events”?
What should hospitals do if a Never Event occurs?
In 2017, the Leapfrog Group issued a list of steps for hospitals to take after a Never Event to ensure that patients and families (and medical providers) receive appropriate follow-up. Here are 9 recommendations for hospital actions after a Never Event:
- Apologize to the patient and family.
- Waive all costs directly related to the event.
- Report the event to an external agency.
- Conduct a root-cause analysis of how and why the event occurred.
- Interview patients and families, who are willing and able, to gather evidence for the root cause analysis.
- Inform the patient and family of the action(s) that the hospital will take to prevent future. recurrences of similar events based on the findings from the root cause analysis.
- Have a protocol in place to provide support for caregivers involved in Never Events, and make that protocol known to all caregivers and affiliated clinicians.
- Perform an annual review to ensure compliance with each element of Leapfrog’s Never Events Policy for each never event that occurred.
- Make a copy of this policy available to patients upon request.
Surgical dangers: medication issues.
A study of more than 275 surgeries during 2013 and 2014 at Massachusetts General Hospital (MGH) found an alarming number of medication problems. Researchers observed the administration of medications during what is called the “perioperative period” – the time immediately before, during and right after a surgery. Their findings indicate a widespread problem. They found:
- At least one medication error or adverse drug event occurred in 44.7% of the surgeries.
- The researchers determined that almost 80% of these events were preventable.
- Medication errors and adverse drug events were more common with longer procedures, especially those lasting over 6 hours with 13 or more medication administrations.
What kinds of errors did researchers identify?
The most commonly observed errors were:
- Labeling mistakes.
- Incorrect dosage.
- Failure to treat a problem caused by a change in the patient’s vital signs.
- Documentation errors.
How serious were these mistakes?
Since all mistakes are not of equal consequence, the researchers classified the mistakes by severity:
- 30% were significant.
- 69% were serious.
- Less than 2% were life-threatening.
- None were fatal.
Why do surgeries have medication issues?
In a 2015 article, Dr. Karen Nanji provides several reasons for this high number of medication issues, including:
- Drugs used during surgery are not routinely screened. In contrast, staff screen all drugs used on inpatient floors.
- The condition of patients in the operating room can change quickly, which may not allow for double and triple-checking medications.
What can you do about medication errors during the perioperative period?
Although there is little you can do to reduce your risk, I suggest you ask your surgeon (and anesthesiologist if possible) what steps he/she takes to reduce your risk of medication errors.
Surgical dangers: simultaneous surgeries.
Did you know that some surgeons simultaneously work on 2 or 3 patients, going between operating rooms? There are two categories for this practice:
- Overlapping – The patient is prepped before the surgeon arrives, the surgeon performs the procedure, and then leaves the “closing” to a trainee or other staff, with a brief overlap at the start and end of cases.
- Simultaneous or Concurrent – More concerning, a surgeon schedules 2 or 3 surgeries to occur simultaneously, working on patients in one operating room, while patients in the other room either wait while anesthetized or have procedures performed by fellows (doctors still in training). The American College of Surgeons considers this practice inappropriate.
Each hospital decides if, and how, they will allow overlapping and/or simultaneous procedures. And, in general, surgeons are not required to notify patients about their plans for either practice.
Is this practice dangerous?
There is less concern about overlapping surgeries since the primary surgeon performs each actual procedure itself, with trainees handling non-critical routine tasks.
In fact, recent research found no increase in deaths or overall complications for overlapping surgeries, but did find a higher risk for major complications such as stroke and heart attack. However, other studies show mixed results for overlapping surgeries. The general consensus is that overlapping surgery is safe for most, but not all, patients.
On the other hand, there are several potential problems with simultaneous or concurrent surgeries:
- A fellow, with minimal experience, will perform portions of the operation without direct supervision of the well-trained attending surgeon.
- When surgeons plan concurrent procedures, they generally plan to be present for the more difficult parts of the operation. However, things do not always go as planned, forcing the surgeon to spend more time than expected with one patient. This delay his/her switch to the other patient. In these cases, the “other” patient may be under anesthesia longer than necessary.
- The start of surgeries can be delayed for 1 or more hours, with the patient anesthetized and ready to go, while the surgeon is busy with another case.
Massachusetts General Hospital practice of simultaneous surgeries.
As you may know, Massachusetts General Hospital (MGH) is considered one of the best hospitals in the country. Yet, according to a Boston Globe article, in February, 2022, MGH agreed to pay $14.6 million to settle a federal lawsuit related to this topic.
The lawsuit alleged that MGH fraudulently billed Medicare for surgeries that were performed by trainees when supervisor surgeons worked in other operating rooms. Importantly, Medicare requires surgeons to be present for at least the critical parts of operations, although some overlapping for non-critical steps is allowed.
This lawsuit was based on allegations made by Dr. Lisa Wollman, an MGH anesthesiologist who stated that at least 5 orthopedic surgeons at MGH regularly kept patients under anesthesia longer than medically necessary (sometimes an hour or more) because the surgeons were working in two operating rooms. Furthermore, she claimed the surgeons failed to designate a backup surgeon in case the trainees required immediate help.
Importantly, this is the 3rd time since 2019 that MGH agreed to pay millions for claims associated with concurrent surgeries.
Furthermore, according to a Boston Globe Spotlight Team series published in 2015, MGH gave orthopedic surgeons financial incentives to perform more procedures, and a handful of doctors regularly scheduled concurrent surgeries to take advantage of this policy.
MGH leaders defend the practice stating it’s the best way to use the most talented surgeons, with surgical trainees performing routine tasks, such as closing surgical wounds, while experienced surgeons operate on other patients. Nonetheless, the reports inspired a national debate in the medical community, a congressional inquiry, and regulatory changes in Massachusetts.
What changes is MGH making?
As part of the latest settlement, surgeons at all hospitals in the Mass General Brigham network must inform patients if they plan to overlap operations with those of other patients.
Unsurprisingly, Dr. Wollman reports that the surgeons she complained about never told patients that they planned on performing concurrent surgeries.
Concurrent surgeries are not limited to MGH.
According to a MedPage Today article, similar cases have been filed against hospitals in Arizona, Pennsylvania, and New York. However, it’s unclear how common this practice is. But, among hospitals who responded to a 2016 survey by the Senate Finance Committee, 33% of surgeries performed between January 2015 and March 2016 had some degree of overlap.
What can you do about simultaneous surgeries?
I suggest you consider the following:
- Ask your surgeon, well ahead of your operation, if he/she will be performing other surgeries at the same time as yours.
- If you learn that your surgeon schedules simultaneous operations, discuss it with your surgeon. If his/her answers don’t satisfy you, you can look for other qualified surgeons in your area.
- You can note your concerns on your consent form. Write that you don’t want a trainee performing any of your surgery without direct, in-person supervision of an attending surgeon.
Clearly, if your surgery is an emergency, or there are no other qualified surgeons nearby, you may not have a choice.
To further reduce your risk of surgical dangers, and to improve your likelihood of a positive outcome, read these posts:
- Questions to Ask Before Surgery.
- Questions Seniors Should Ask Before Surgery
- You Can Improve Your Surgical Outcome.
- What is the Best Time of Day for Medical Care?
- Recover Faster After Surgery.
- How Safe are Surgery Centers?
NOTE: I updated this post on 3-18-22.