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Surgical “Never Events”

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

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Surgical “Never Events”

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  1. Surgical “Never Events” Serious Medical Errors in Surgery that Should Never Happen to a Patient Melody Shaw

  2. 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 EagleEye, 2013

  3. Statistics of Surgical “Never Events” 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)

  4. “Time Out”

  5. 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 6th 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)

  6. 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)

  7. 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

  8. 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

  9. 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)

  10. Resources

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