Tag: Four to nine factors contributed to each ‘never event

Four to nine factors contributed to each ‘never event,’ study finds
Health

Four to nine factors contributed to each ‘never event,’ study finds

[caption id="attachment_24660" align="alignleft"]shutterstock 232603318gallbladder removal, surgery in the operation theatre[/caption]ROCHESTER, Minn. — Why are major surgical errors called “never events?” Because they shouldn’t happen — but do. Mayo Clinic researchers identified 69 never events among 1.5 million invasive procedures performed over five years and detailed why each occurred. Using a system created to investigate military plane crashes, they coded the human behaviors involved to identify any environmental, organizational, job and individual characteristics that led to the never events. Their discovery: 628 human factors contributed to the errors overall, roughly four to nine per event. The study results are published in the journal Surgery.

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