Friday, June 4, 2010

"Never Events" Still On The Rise In California

With all of the efforts hospitals have put into quality improvement and patient safety, it is discouraging indeed to read a report like the one issued recently by the California Department of Public Health. The report highlighted that "never events", particularly leaving foreign objects in patients following surgery, are on the rise. Last year California hospitals reported 197 cases of retained foreign objects which brought the two year total to 350. That's 14% of all the preventable errors reported during that two year period.

What's going on with these hospitals? I understand that we are dealing with a complex situation that is run by humans who are prone to error, but where are the checks and double checks in the procedure to account for the possibility of error? San Francisco General Hospital after being fined by the state for leaving a surgical sponge in a patient, has now changed its policies to significantly reduce the likelihood of this happening again. Good for them, but why did it take a fine to motivate them to do something that should have been done long before this?

There are high tech solutions being applied to this such as bar codes and radio frequency detection systems, but it still boils down to checks and double checks of all instruments, pads and sponges used during a procedure. There is no single solution that can be universally applied to all hospitals. It is human nature that after years of double checks that never find a missing sponge to get lax and not catch the one that finally happens.

Penalties and fines are not the answer to change culture. Facing public exposure of such errors is probably a stronger deterrent. But building a culture of patients first is the only real way to address this issue. Because we are human, we probably can't keep this number at zero. But we can sure do a darn sight better than we saw last year in California.

More on this later.

Mark Brodeur

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