Stopping a ‘Never Event’ – Please read and think about it. Could happen to you.

A recent happening at a Hospital in the US.

A surgical department called for a patient to be transported…..and a patient was transported to the department.

The wrong patient.

So, the nurse gave the correct patient name to the secretary, who gave the wrong name to the nurse.  That nurse gave the name of her patient (who was not having a procedure) to transport.  Transport brought the patient.

And thankfully, the nurse in the surgical area checked the ID band.  Because the patient said, “Well, I might need (this specific surgery that is done in this department)”. error

So we all know what a Never Event is, but I am going to post information anyway. These are the ‘never’ surgical events, from the National Quality Forum:

1. SURGICAL OR INVASIVE PROCEDURE EVENTS

1A. Surgery or other invasive procedure performed on the wrong site (updated)
Applicable in: hospitals, outpatient/office-based surgery centers, ambulatory practice settings/office-based practices, long-term care/skilled nursing facilities

1B. Surgery or other invasive procedure performed on the wrong patient (updated)
Applicable in: hospitals, outpatient/office-based surgery centers, ambulatory practice settings/office-based practices, long-term care/skilled nursing facilities

1C. Wrong surgical or other invasive procedure performed on a patient (updated)
Applicable in: hospitals, outpatient/office-based surgery centers, ambulatory practice settings/office-based practices, long-term care/skilled nursing facilities

1D. Unintended retention of a foreign object in a patient after surgery or other invasive procedure (updated)
Applicable in: hospitals, outpatient/office-based surgery centers, ambulatory practice settings/office-based practices, long-term care/skilled nursing facilities

1E. Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient (updated)
Applicable in: hospitals, outpatient/office-based surgery centers, ambulatory practice settings/office-based practices

The things we do to Prevent these events:

  1. The person who is actually performing the procedure must Mark the site.
  2. ID Must be checked by EVERYONE involved in a handoff of a patient.
  3. We include the procedure in the time-out, and the surgeon, and all people involved with the surgery have verified that the patient is having this procedure and consents to it.
  4. We Count sponges, sharps, etc at the beginning and ending of every case.
  5. We do it right, and pay attention.

Simple enough, right?

vitals_hazards.190.1What happens when you are busy?  Naturally, you do the same things, no matter what.

Unless…

  • The Secretary had four family members at the desk yelling at him, misheard the nurse on the phone, and gave the nurse on the floor a sound-alike name.
  • The nurse on the floor has seven patients on telemetry, and is juggling admissions, discharges, and procedures.  He has had no time to talk to any medical staff, and assumed the procedure was an add on, since the patient had a similar problem.
  • The transporter takes the patient, who has no idea what is going on. The patient trusts the hospital, and the nurse, and doesn’t ask any questions.
  • The nurse in the surgical area immediately verifies the ID band with the OR schedule.  It does not match.  She figures out what happened, and sends the patient back
  • The procedure is done on the correct patient, after the mistake is fixed.

This is why we do the things we do.  That patient could very well have had the wrong procedure done. The surgeon had only briefly met the patient, and we hope that he would have remembered that this was a different face, and checked the ID band himself. We hope the patient would have realized that no one talked to him about the invasive procedure he was about to have done.  We hope that the staff actually did the time out they charted.never

We are members of a profession that owns the trust of the public. We do these things with every patient, every single time because we know that never events are possible.  Perhaps our hospitals and other healthcare facilities can help us prevent never events by staffing us appropriately. Because nobody is perfect.

Love,

 

Janie

 

 

 

 

 

Share this post with friends!
Facebooktwitterpinterestmail
Want More? Click below to follow us!
Facebooktwitterinstagram

Author Janie Garner

More posts by Janie Garner

Leave a Reply