SURGICAL NEVER EVENTS Serious Medical Errors in Surgery

SURGICAL “NEVER EVENTS” Serious Medical Errors in Surgery that Should Never Happen to a Patient Melody Shaw

Surgical Error Blamed on Circulating Nurse 15 year old boy goes into surgery to remove the right side of the brain to prevent epileptic seizures The surgeon entered the left side of the brain, and started removing part of the left brain. The patient came out of surgery and the parents were informed of the mistake as “minor and inconsequential” After graduating high school, the boy was placed in an assisted living facility The family filed a lawsuit and won $11 Million but that will not touch the pain and suffering they have had to endure Legal Eagle. Eye, 2013

Statistics of Surgical “Never Events” Type Of “Never Event” Cases Average Payout Wrong Procedure 2, 447 $232, 035 Wrong Site 2, 413 $127, 159 27 $109, 648 Wrong Patient Retained Foreign Body 4, 857 $86, 247 About 80 times each week a surgical “Never Event” occurs Annual Rate of 4, 082 surgical “Never events” Approximately 1 surgical “Never Event” occurs every 12, 248 Surgeries Average payout each “Never Event” is $133, 055 which is over $5 Million (O’Reilly, 2013)

“Time Out”

A Simple Surgery Gone Wrong A C-Section was performed on a patient and she was discharged Her stomach started growing again over the next month, and by the 6 th week her bowels had completely shut down A surgical sponge was left in her abdomen She had to stay in the hospital for 3 weeks and still takes medication to regulate her bowels today She was also informed it is not recommended for her to have another child (Eisler, 2013)

The Family and a Lawsuit A 2 year old tripped while running and fell face first onto a sharp stick that penetrated deep into his mouth He was feeling sick a few days later and the family requested a brain scan… healthcare staff said no Steven ended up with a ruptured abscess on his brain and is now severely brain damaged The family sued the hospital and got $7. 1 million for pain and suffering, $4. 1 million in economic damages for a total of 11. 2 million (Stewart, 2011)

What happened to the money? ¼ of the 1. 4 million went to lawyers fees $115, 000 went towards the expert witnesses $100, 000 went towards private school for the disabled. The mother had to quit her job, and they had to move into a larger home that could accommodate their son and then remodel it so he can maneuver The child has had 23 surgeries and regular preventative appointments with specialist He is currently covered under his dad’s insurance, but once he hits the age limit he will be taken off

What can we do to help as Nurses Ensure that consent form is properly filled out and signed – and the patient understands what they are signing Ensure that correct surgical site is marked Ensure that “Time Out” is completed as soon as patient enters the operating room Document everything that is completed on the patient. Work as a team

In the future… In a perfect world, the number of surgical never events will be at zero The Joint Commission requires accredited hospitals to follow the Universal Protocol � They are pushing each state to have a standardized checklist used in every acute care hospital by the end of 2013 � They want to have “Safe Surgery” by 2015 (Butcher. 2011)

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