How to Make ‘Never Events’ as Rare as Possible

Retained surgical items, wrong surgeries and patient falls are ever-present challenges to overcome.

Sentinel events are often referred to as “never events” because of the potentially serious harm they pose to patients that should never happen. The reality is that they are problems that are never fully solved.

They can be reduced, however.

The Joint Commission (TJC) Sentinel Event Data 2024 Annual Review is a reminder of this, according to Michael Suk, MD, JD, MPH, MBA, FACS, FACHE, chairman of the TJC Board of Commissioners.

The nonprofit agency evaluates and accredits healthcare organizations to ensure they are delivering high-quality care to patients and is recognized by the Centers for Medicare & Medicaid Services (CMS) for accrediting agencies that meet or exceed its requirements.

“The 2024 report confirms what a lot of people in the field already feel — that preventable harm still is a clear and present challenge for us in health care, particularly in the procedural environments like ambulatory surgery centers (ASCs),” says Dr. Suk, who notes that ASCs are performing increasingly complex procedures, operate with speed and efficiency and often deal with resource constraints.

“While sentinel events in the ASC setting comprised only 37 of the 1,575 reported events in 2024, ultimately that impact is disproportionate and preventable, and they can have devastating consequences,” he says. “Things like wrong-site surgeries, retained foreign objects, delays in treatment and surgical fires each represent really important points in safety and can indicate some opportunities for real improvement.”

The costs of these events are high. Dr. Suk notes that each incident carries a price tag of more than $500,000. “The patient also suffers, needing additional surgery, a prolonged recovery and the emotional trauma of having to go through a procedure more than once,” he says.

Unintentionally retained surgical items

FIRE HAZARDS Light sources and Bovie cords are among the sources of surgical fires.

There were 119 reports of a retained foreign object in 2024, the fourth year in a row that number rose. Forty-three percent of those incidents resulted in severe harm to the patient, 80% of which was temporary harm, according to TJC’s data report.

“Sponges accounted for about 34% of those 119 reported events, with OB/GYN procedures representing a significant portion of them,” says Dr. Suk. “While it’s a concerning rise, it highlights an area for potential improvement.

“The Joint Commission continues to advocate for a strict adherence to manual count protocols of sponges and other items after surgery,” he says. “The advent of technology opens up the door for other redundancy strategies like radio frequency detection, which is becoming increasingly popular. And at the end of the day communication is vital, with an emphasis on having a debrief to understand where the discrepancies occurred and getting to the root cause of them. It’s important to create that atmosphere where people in the room are paying heightened attention to the possibility of retention, especially during higher-risk areas of surgery.”

Retained fragments of instruments or devices such as catheters, drill bits, suture devices and uterer stents comprised 17% of the retained objects in the report. Twelve retained guide wires were reported — half of which were associated with bedside central/ midline or femoral line placements. Retained retractors and clamps were leading examples of the 13 reported instruments left behind. The 27 assorted other retained items reported included mesh, syringe caps, wound dressing and pins or screws.

Wrong surgeries

These events were the second-most reported to TJC in 2024 (falls were by far the most frequently reported event). There were 127 wrong-site, wrong-procedure or wrong-patient incidents reported. Thirty-eight percent of the 37 reports from ambulatory settings were wrong-site events, the most type of sentinel incidents reported from those settings.

“We know historically, and also from the report, that the most common causes for these are a missed or an incomplete time out. The second reason is poor communication during the pre-op handoff,” says Dr. Suk.

“Ultimately these are linked to the culture of a facility, which really centers on the idea that we should speak up, stop the line or raise concerns without fear.”

TJC’s standards require a rigorous three-step verification process: a thorough pre-procedural verification, site marking and a time out before incision.

“The culture that we talk about — where the members feel engaged and empowered to stop the line or stop the procedure — fosters continual improvement,” says Dr. Suk. “We agree with AORN that these time outs need to be interactive and deliberate and not performative. When they’re done correctly, they’re probably the most effective moments in which we can catch an error before they reach the patient.”

It’s important to note the difference between the time out and the preoperative pause.

“Sentinel reporting is a symbol of integrity and a support for a culture of continuous improvement.”
—Michael Suk, MD, JD, MPH, MBA, FACS, FACHE

“The pre-op pause is a high-level safety check done before the patient enters the operating room, when the teams get confirmation on the patient’s identity, the procedure that is about to be performed, their readiness for surgery and their consent,” says Dr. Suk. “The time out is conducted in the operating room where all team members are present and actively participating. It has to occur before the incision to prevent any potential harm.”

There are two critical junctures of patient handoffs. One is when the patient leaves the pre-op area into the operating room. The other is when they leave the OR and go to the postoperative area.

Team members from each area should be directly involved in the handoff. For example, anesthesia should be involved directly to make sure the pre-op pause is correct and then they’ll do the same during the handoff into the postoperative area, which also includes the circulator nurses that accompany the patient, says Dr. Suk.

“I think the data certainly demonstrates that when organizations do pre-op pauses and time outs, and they do them in a complementary fashion, we get higher compliance that ultimately leads to lower incidence of wrong events, whether it’s the procedure or the location,” he says.

Fires and burns

Fires and burns were the second-most type of sentinel event from ambulatory settings, making up 14% of the 47 incidents reported from ASCs.

“These types of incidents can definitely cause significant harm,” says Dr. Suk. “They are often linked to things like the light sources, electrical-surgical unites, Bovie cords or oxygen-rich environments.”

TJC recommends that staff are aware of the potential dangers of surgical fires and trained in fire-prevention techniques. Team members should be given clear assignments and know their roles in the rare event a fire breaks out, says Dr. Suk. The potential for fires should also be mentioned in the time out.

“During the time out, you not only identify the patient, the location of surgery and the procedure that’s about to be performed but also assess the fire risk so that people in the room are aware,” he says. “That’s now part of the mandatory time out process and was included in one of our Sentinel Event Alerts.”

Reporting is not admission of failure

Because reporting sentinel events to The Joint Commission is voluntary, the agency says no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

Dr. Suk strongly encourages organizations to report these events, even though they aren’t required to do so. “The reason for this voluntary model is really quite intentional,” he says. “It’s designed to foster candor, psychological safety, etc., which brings an atmosphere of honest introspection versus a defensive kind of posture. The Joint Commission is eager to work with organizations, and we have patient safety specialists who are available to provide extra support.”

Dr. Suk believes that organizations who are open and honest in their reporting foster an atmosphere of collaborative learning, and that such transparency builds trust within organizations that ultimately elevates public confidence.

“There’s a frequent notion that The Joint Commission has policy that results in some punitive punishment. It’s not about that. It’s about fostering a culture revolves around the concept of continual improvement in patient safety,” says Dr. Suk. “We don’t consider reporting a sentinel event a weakness. We consider it as a sign and symbol of integrity to the healthcare system and a support for a culture of continuous improvement.” OSM