“Never events,” according to the National Quality Forum, are those mistakes that occur during medical care that are:
- Clearly identifiable;
- Easily preventable;
- Serious in their consequences for patients;
- Indicate major problems in the safety and credibility of a health care center.
They include things likes mismatched blood transfusions, major medication errors, surgery on the wrong body part and pressure ulcers/ bedsores. They also include items, like surgical sponges, left inside a patient after surgery. Yet the Institute of Medicine estimates more than 100,000 such incidents occur annually, resulting in more deaths than car accidents and more than $9 billion in excess charges.
A recent analysis published in the New England Journal of Medicine details a case wherein a 42-year-old woman reported to a primary care center with bloating – only to discover in a CT scan that two gauze sponges had been left inside her abdomen from one of two (or both) prior C-section surgeries – one six years earlier and one nine years earlier. CNN reports she’d had no prior abdominal or pelvic surgeries. Continue reading