Never Event
en.wikipedia.orgThe USA list is an interesting conflation of what I think are two distinct classes of error: ones which can be made impossible with the right processes followed correctly, and ones which can't.
"Wrong site surgery", "retained instrument post-operation", "infant discharged to wrong person", sure, absolutely agree processes can and should be such that this can literally never happen.
On the other hand, "Intraoperative or immediately postoperative death in an ASA Class I patient" seems like one which is ultimately in the lap of the gods: we certainly can and should make those odds really good (maybe much better than they currently are) by improving processes and ranking surgeons by their error statistics and so on. But sometimes people do just die, and the best surgeon could make a one-in-one-thousand slip of the hand (because human bodies just aren't built for such perfect fine motor control). And "serious injury or death associated with a fall": again, I'm not sure there are processes even in principle which could prevent a determined patient from injuring themselves by taking a fall, short of tying them to the bed or otherwise disabling them. There's a solid chance I, a basically-healthy patient in a ward, could be socially engineered into helping the miserable elderly patient next door to get out of bed for a short walk; so now your processes need to be robust to having young healthy people actively trying to break them! This problem seems not like the others.
Agreed, the no-suicide one is the worst. What process would you even take other than asking "have you had suicidal thoughts?"
It said "while being cared for in a healthcare facility." You can watch people and not leave dangerous objects around the room.
Depends n your definition of dangerous objects. For example, sheets?
Beds in psych wards usually have sheets. Suicide prevention is not like stopping the sane, rational Epstein from avoiding prosecution, it is more like checking in on people going through an awful experience every so often.
> Infant discharged to the wrong person
When our daughter was born, we didn't let her out of our sight until my wife left the hospital. Sure, they have these bracelets that prevent switching babies (which happened to my wife's grandmother in 1960ies Switzerland), but our worst nightmare was that someone simply took and walked out with her.
Our children each had multiple bracelets, and when one bracelet had to be moved, it was a process involving multiple individuals and had clearly been rehearsed. Each kiddo also had a "baby LoJack" that went off and locked down the entire place if they were moved past a certain line near all doors; we accidentally set it off once and the reaction was immediate.
Sometimes it felt like it was overdone, and sometimes it felt like the most important thing in the world.
A friend of mine has experienced Never Event #8 (Surgery performed on the wrong body part), went in for work on a tendon in her right ankle, woke up with a cast on the left leg.
edit: scrolled further and saw that in the UK we have a different list, so I guess this would count as "Wrong site surgery"
My friend is a surgeon. When he went in for knee surgery he wrote "Wrong Knee" on the good knee. He knows.
I've known people who have been asked by the surgical team to mark their own surgical site. But marking off the easy mistake in addition is even better.
I believe it’s common in the US for the intended (and/or unintended) surgical site to be physically marked in ink before the surgery to prevent left-right mistakes.
Also in the UK. E.g. a big arrow pointing in the general direction of the site, and a dotted circle around the site itself. The low-tech ways are the best!
I do remember reading about a case where they have marked the wrong place on the head where to drill a hole because they had the wrong patient.
can you elaborate? What did they actually do to the left leg?
The surgery they were going to do on the right one...
but if the surgery is something like 'remove pin' how do they manage to perform that on the wrong leg?
Sounds a bit odd to use "never event" for things that can and do happen - but actually I like the term, because it at least expresses the desire to reduce these events as much as possible. Same as https://en.wikipedia.org/wiki/Vision_Zero for traffic deaths.
I think policies like vision zero are a complete governance anti-pattern. When you commit to a goal that is very literally impossible, it can be used as a justification for just about any action that would move the needle closer to the never-achievable target, no matter how insane that action might be.
It is the complete opposite of sensible risk management, and serves only the politicians who find it difficult to publicly admit the fact that some level of risk must be accepted, which isn’t something I think the public should encourage.
It also removes any level of accountability for actually having to achieve a goal, because no achievable goal was ever defined to begin with.
If you asked somebody in the sixties whether it would be possible to have no airplane crashes, they would have laughed at you. And yet, the last crash of a commercial flight in the US is now 14 years ago.
Of course, if everyone agrees that a goal isn't achievable (or it's not worth the effort to achieve it), then it will never be achieved...
Airliner safety boggles my mind. It's sort of banal, but mastering of such a complex system in a safe way is also one of the greatest achievements of human kind. So many things which can go wrong, yet it works.
This proves the exact opposite of what you think it proves. Planes crash all the time. Commercial planes also crash all the time if you want to be extra specific.
Commercial Airline flights definitely don't crash "all the time."
Gonna need you guys to read CFR 61 and 141 real quick or this discussion is going to languish. More or less: scheduled commercial airline service like American Airlines 587 which crashed into NYC shortly after 9/11 falls under part 141 and crashes are extremely rare.
However, certain commercial operations like air taxis and flight instruction fall under the much less restrictive part 61 and there are tons of incidents all the time.
Original poster meant to say part 141 has been very good at making airline safely profoundly good lately.
I remember watching a surgeon-narrated YouTube video demonstrating eye removal, and didn't feel any stomach-turning horror from seeing the gore. I felt it when the narrator told to check something "to ensure the correct eye is being enucleated".
These numbers are way too low:
> As of 2019, 11 states have mandated reporting for never events, and an additional 16 states have mandated reporting for serious adverse events including never events.