“Never Events” in Surgery Stephen D. Cassivi, MD MSc FRCSC FACS Professor of Surgery Vice Chair – Department of Surgery [email protected]
Jan 12, 2016
“Never Events” in SurgeryStephen D. Cassivi, MD MSc FRCSC FACS
Professor of Surgery
Vice Chair – Department of Surgery
Financial Relationship / Conflict of Interest Disclosure
Statement
I have NO financial relationships or
potential conflicts of interest to report
Audience Response Questions
Never Events in Surgery
Which of these following events is the most commonly reported
‘Never’ event?A. Abduction of inpatient
B. Inpatient SuicideC. Wrong-site
Surgery
Source: 2009 Joint Commission Report
Never Events in Surgery
Which of these following events is the most commonly reported
‘Never’ event?A. Abduction of inpatient
B. Inpatient SuicideC. Wrong-site
Surgery
Source: 2009 Joint Commission Report
Never Events in Surgery
Of the following 4 surgical ‘Never Events’, which is the most common?
A. Surgery on the wrong body part
B. Surgery on the wrong patientC. Unintended retention of a
foreign objectD. Wrong surgical procedure
performed
Never Events in Surgery
Of the following 4 surgical ‘Never Events’, which is the most common?
A. Surgery on the wrong body part
B. Surgery on the wrong patientC. Unintended retention of a
foreign objectD. Wrong surgical procedure
performed
Never Events in Surgery
Of the following 4 surgical ‘Never Events’, which is associated with the
highest average malpractice payments?
A. Surgery on the wrong body part
B. Surgery on the wrong patientC. Unintended retention of a
foreign objectD. Wrong surgical procedure
performed Source: Surgery 2013:153;465-472.
Never Events in Surgery
Of the following 4 surgical ‘Never Events’, which is associated with the
highest average malpractice payments?
A. Surgery on the wrong body part
B. Surgery on the wrong patientC. Unintended retention of a
foreign objectD. Wrong surgical procedure
performed (~ $230,000/case)Source: Surgery 2013:153;465-472.
Never Events in Surgery
“Never Events” in SurgeryStephen D. Cassivi, MD MSc FRCSC FACS
Professor of Surgery
Vice Chair – Department of Surgery
“Never Events”
“Never Events”
“Never Events”
“The defense strenuously objects.”
“Never Events”
Ken Kizer, MD MPH• Founding President and
CEO – National Quality Forum
Which of these have you done in the past year?
A. Paid for an Insurance Policy
B. Purchased a Lottery ticket
C. Both A & BD. Neither A or B
Never Events in Surgery
Negative Framing
Daniel Kahneman, BA PhD
2002 Nobel Prize in Economics
When the consequences of failing
to act are mentally vivid,
humans are more strongly inclined
to take action when the actions
are labeled so as to convey the
loss avoided rather than the benefit
gained.
“Never Events”
Wrong-Site Surgery
~ 1/112,000 surgical procedures
~ 4000 cases / year
“Never Events”
29 “Serious Reportable Events”
Growing list of: “Non-Reimbursable Serious Hospital-Acquired Conditions”
NQF – SREs
1. Surgery on the wrong site2. Surgery on the wrong patient3. Wrong surgical procedure4. Unintended retained foreign object5. Death in an ASA I patient
• Device related death• Hospital-acquired burns• Falls• Pressure ulcers (stage 3 or 4)
CMSNon-Reimbursable Serious Hospital-Acquired Conditions
Beyond the NQF• Catheter-associated UTI
• Vascular catheter-associated infection
• SSI after CABG
• SSI after Bariatric surgery
• SSI after orthopedic surgery
• DVT in total knee or hip replacement
“Never Events”
“Never Events”Steps to take
“Never Events”Steps to take
1. Recognize that it’s not just on you.
“Never Events”Steps to take
1. Recognize that it’s not just on you.
“Never Events”Steps to take
1. Recognize that it’s not just on you.
2. Develop and standardize Evidence-based / Best Practices
“Never Events”Best Practices
“Never Events”Steps to take
1. Recognize that it’s not just on you.
2. Develop and standardize Evidence-based / Best Practices
3. Nurture a culture of safety
“Never Events”Measured Optimism
“Fortunately, in the last six years, we’ve
witnessed remarkable improvements and
innovative solutions emerge in response to
review of these Serious Reportable Events.”
Dr. Janet CorriganNQF President and CEO