“Never Events” in SurgeryStephen D. Cassivi, MD MSc FRCSC FACS

Professor of Surgery

Vice Chair – Department of Surgery

cassivi.stephen@mayo.edu

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

cassivi.stephen@mayo.edu

“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

cassivi.stephen@mayo.edu