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Editor's Page
Think Never Events Never Happen?
Dan O'Connor
Publish Date: December 14, 2007

Maybe these things happen at other facilities, but never at yours. These are things that make you cringe and count your lucky stars when you see them on the evening news or read about them in the newspaper.

Wrong-site surgery, wrong-person surgery, wrong-procedure surgery ...

They call them never events not because they never happen, but because they never should happen. They're not supposed to happen, but these inexcusable failures in medical care often do.

Retained objects ...

Intraoperative or immediately post-op death in a normal health patient ...

A hospital OR manager we spoke to on the condition of anonymity told us of not one, but two cases of retained objects that happened four years apart.

In the first, a surgeon left a 12-inch malleable retractor inside of a woman who was undergoing a bowel resection. The surgeon was closing the patient, suturing over the retractor he had laid inside the patient. He never slid the retractor out.

The woman developed a fever, chills, and nausea and vomiting 36 hours post-op. An X-ray revealed the problem in black and white. The patient was back in surgery, subjected to another batch of antibiotics, more post-op pain and nausea and unnecessary anesthesia.

The (traveling) scrub tech and the (new) circulating nurse said the counts were correct.

"They jumped the gun on the counts," says the OR manager. While the surgeon was closing, the tech and the circulator counted the instruments and announced prematurely that all counts were correct. The manager chalked it up to inexperience and surgeon intimidation. The hospital switched from a malleable retractor to a self-retaining retractor.

The second incident involved a lap sponge that the surgeon pushed deep into the pelvis cavity of a woman undergoing abdominal surgery. A scrub tech and nurse verified that the sponge count was correct, but the team that relieved them during a shift handoff didn't verify the count. The lesson learned: Separate sponges as you count them because two stuck together can easily look like one.

"People who are in a rush don't take the time to ensure the proper count," says the OR manager. "You must be diligent. Make sure circulators are watching the sterile field to see what's coming off and what's coming on. I don't think you can be too careful. You've got to put the patient first."

You'll find plenty of advice on safe practices and even more reviews of safety devices in this year's annual safety issue. But if you don't put the two together, it's like blowing through red lights while driving a safety-engineered Volvo.