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Avoiding near misses and never events
PERIOP BRIEFING
EDITORIAL
Avoiding near misses and never events Kelly Putnam, Managing Editor
I
n one of his hit songs, Billy Joel sings, “You’re only human, you’re allowed to make your share of mistakes.”1 This line speaks to our culture’s general acceptance of making mistakes—that they often offer important opportunities for learning, improvement, and growth. To a point, this is true for the delivery of health care, but there is a fine line in high-stakes environments beyond which mistakes are unequivocally unacceptable, and preventing these mistakes is a high priority for all health care providers.
Never events—also called sentinel events—are defined as serious, preventable surgical events that can impose a high physical and emotional toll for patients, their families, and perioperative personnel.2 The reversibility of the event determines the extent of trauma experienced by patients and personnel, and notably, some events cause irreversible damage.2 Examples of never events include wrong-patient, wrong-site, and wrongprocedure events; retained surgical items; and fires in the OR.3 Research regarding the incidence and contributing factors of these events continues to expand, and resources from organizations such as AORN provide strategies to help perioperative personnel reduce the occurrence of these events.4 Root cause analyses guide the design of prevention efforts, which need to be evaluated to determine their effectiveness. Reducing the incidence of one type of adverse event may require a targeted approach that relies heavily on personalized risk assessments and individual nursing judgment, but for other types of events a broader, more global approach may prove more effective. For instance, is it better to assess each patient’s fall risk and tailor the interventions to each patient, or treat all patients as if they present an equally high risk of falling? This question can be applied to different patient populations and outcomes, and each facility and perioperative team must validate their practices within their own setting. The effectiveness and sustainability of preventive measures determine the http://dx.doi.org/10.1016/S0001-2092(15)01008-X
P4 | Periop Briefing
ultimate success of programs intended to eliminate never events. Unlike never events, errors that result in near misses do not cause severe patient complications; when the learning from a near miss is applied to practice, the improvements to patient outcomes are more subtle, such as shorter procedure times or reduced need for blood transfusions. A near miss and its context can offer valuable learning opportunities for team members when identified and evaluated in a timely manner. For instance, intraoperative recordings of the procedure itself and the dynamics within the OR can show a resident how to handle a tissue more delicately or reveal unproductive communication among team members. Despite the advantages of adopting recording technology into the OR, the medico-legal barriers may prevent more widespread use. Addressing preventable errors and events is a theme running through this month’s issue of Periop Briefing, which examines programs to reduce patient falls, updated recommendations to prevent retained surgical items, and new methods for monitoring near misses that result from technical and non-technical errors among perioperative team members. I hope this issue gives you reason to pause and consider ways you and your team members could learn more from near misses, and avoid preventable mistakes altogether. References 1. Joel B. You’re only human (second wind). In: Billy Joel’s Greatest Hits Volume I & Volume II. Los Angeles, CA: Family Productions/Columbia; 1985. 2. Kobiela J, Kobiela P. Emotional aspects of never events. JAMA Surg. In press. 3. Berger ER, Creenberg CC, Bilmoria KY. Challenges in reducing surgical “never events.” JAMA. 2015;314(13):1386-1387. 4. Prevention of sentinel Events. AORN. http:// www.aorn.org/sentinelevents/. Accessed November 13, 2015.
EDITORIAL
Avoiding near misses and never events Kelly Putnam, Managing Editor
I
n one of his hit songs, Billy Joel sings, “You’re only human, you’re allowed to make your share of mistakes.”1 This line speaks to our culture’s general acceptance of making mistakes—that they often offer important opportunities for learning, improvement, and growth. To a point, this is true for the delivery of health care, but there is a fine line in high-stakes environments beyond which mistakes are unequivocally unacceptable, and preventing these mistakes is a high priority for all health care providers.
Never events—also called sentinel events—are defined as serious, preventable surgical events that can impose a high physical and emotional toll for patients, their families, and perioperative personnel.2 The reversibility of the event determines the extent of trauma experienced by patients and personnel, and notably, some events cause irreversible damage.2 Examples of never events include wrong-patient, wrong-site, and wrongprocedure events; retained surgical items; and fires in the OR.3 Research regarding the incidence and contributing factors of these events continues to expand, and resources from organizations such as AORN provide strategies to help perioperative personnel reduce the occurrence of these events.4 Root cause analyses guide the design of prevention efforts, which need to be evaluated to determine their effectiveness. Reducing the incidence of one type of adverse event may require a targeted approach that relies heavily on personalized risk assessments and individual nursing judgment, but for other types of events a broader, more global approach may prove more effective. For instance, is it better to assess each patient’s fall risk and tailor the interventions to each patient, or treat all patients as if they present an equally high risk of falling? This question can be applied to different patient populations and outcomes, and each facility and perioperative team must validate their practices within their own setting. The effectiveness and sustainability of preventive measures determine the http://dx.doi.org/10.1016/S0001-2092(15)01008-X
P4 | Periop Briefing
ultimate success of programs intended to eliminate never events. Unlike never events, errors that result in near misses do not cause severe patient complications; when the learning from a near miss is applied to practice, the improvements to patient outcomes are more subtle, such as shorter procedure times or reduced need for blood transfusions. A near miss and its context can offer valuable learning opportunities for team members when identified and evaluated in a timely manner. For instance, intraoperative recordings of the procedure itself and the dynamics within the OR can show a resident how to handle a tissue more delicately or reveal unproductive communication among team members. Despite the advantages of adopting recording technology into the OR, the medico-legal barriers may prevent more widespread use. Addressing preventable errors and events is a theme running through this month’s issue of Periop Briefing, which examines programs to reduce patient falls, updated recommendations to prevent retained surgical items, and new methods for monitoring near misses that result from technical and non-technical errors among perioperative team members. I hope this issue gives you reason to pause and consider ways you and your team members could learn more from near misses, and avoid preventable mistakes altogether. References 1. Joel B. You’re only human (second wind). In: Billy Joel’s Greatest Hits Volume I & Volume II. Los Angeles, CA: Family Productions/Columbia; 1985. 2. Kobiela J, Kobiela P. Emotional aspects of never events. JAMA Surg. In press. 3. Berger ER, Creenberg CC, Bilmoria KY. Challenges in reducing surgical “never events.” JAMA. 2015;314(13):1386-1387. 4. Prevention of sentinel Events. AORN. http:// www.aorn.org/sentinelevents/. Accessed November 13, 2015.