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A 70-year-old man from Alabama recently died at a hospital in Florida when a surgeon mistakenly removed his liver instead of his spleen.
This type of medical error is known as a “never event” because it should never have happened. Unfortunately, they happen all too often.
Never events range from the wrong organ or side being operated on, the wrong prosthesis (such as hip joints) being inserted, to foreign objects (typically surgical instruments and swabs) being left inside the patient.
In the UK, provisional NHS data shows that between April 2023 and March 2024, there were 370 never events. In the three years prior to that, the figures were, in reverse order, 384 (2022-23), 407 (2021-22) and 364 (2020-21). So, roughly, one of these events occurs each day. Given the number of procedures performed daily by the NHS, these figures are impressively low. Although I suspect that would be cold comfort for anyone affected by one of these often life-changing errors.
In the US, there has been a recent increase in never events, with 1,440 in 2022 and 1,411 in 2023. Before this, never events were less than 1,000 a year. In 2023, 18% of these events resulted in the patient dying and 8% in permanent harm or loss of function.
What are the most common errors?
Considering the man from Alabama, it is difficult to see how a surgeon might confuse the spleen and liver given that the basics of anatomy are taught early in medicine. And then, the subsequent years of postgraduate training see doctors focus on areas of their specialty, such as general surgery, orthopedics, neurology, and others, which further reinforces their knowledge of their chosen specialty region.
Many surgical careers take at least 15 years of medical training to achieve in the UK and similar lengths of time in the US and elsewhere. However, it is well recognized that where these errors take place, they are often multifactorial.
The most common errors are seen on the wrong side of the body. Humans are symmetrical in many ways, with pairs of various organs, so confusion over the left and right happens.
In urology, studies have shown that in over 10% of cases clinical letters fail to mention the diseased side (8.7%) or they mention the wrong side (3.3%). And sometimes radiology images are placed on the screen the wrong way around. These things can lead to patients having their healthy kidney removed rather than the diseased one.
Other paired structures that are often removed from the wrong side are testicles, which can leave patients infertile.
Similar surgical errors have affected women’s fertility, with surgeons removing the wrong uterine (fallopian) tube. In other errors, healthy ovaries have been removed or, at least in one case, removed in error (it should have been the pregnant woman’s appendix that was removed), sadly leading to the patient’s death.
A study from the US suggests that the most likely surgical specialty to perform wrong-site surgery was orthopedics (35%), followed by neurosurgery (22%) and then urology (9%).
Others have confirmed orthopedics as having one of the highest rates of wrong-site surgery – 21% of hand surgeons confirmed they’d operated on the wrong site.
Sometimes other circumstances, such as mistaken identities and clerical errors, result in death. For example, a hospital in the Bronx, New York, turned off the life support of the wrong patient. In another tragic case, a 17-year-old girl was given a donor’s heart and lungs, but they were blood-group incompatible. She died shortly after.
These types of errors are rarely published in medical journals, probably due to the legal implications. So the media is often the first source to detail these errors. However, media reports tend to contain limited relevant medical information that might enable wider lessons to be learned from these cases.
Never events have huge implications for patients and their families, and many of them result in significant payouts. The cost of settled claims paid out by the NHS in 2015-20 was over £17 million. And, globally, between 1990 and 2010 claims were over US$1.3 billion (£990 million).
Safety checklists
There is continuing progress towards eliminating never events. In 2008, the World Health Organization (WHO) launched the surgical safety checklist, which was adopted by the NHS in 2009.
Similar protocols have been used in the US since 2004.
These sorts of protocols bring consistency across healthcare providers, and shortly after the WHO’s checklist was introduced, it was shown to reduce post-operative complications and deaths by 36%. However, as the statistics on never events show, there is still plenty of room for improvement.
As the demand for healthcare increases, systems have to adapt to ensure patient safety is not compromised. Given that so much appears to be linked to human factors, appropriate staffing, workload, and welfare will all be of paramount importance.
Adam Taylor is a professor and the director of the Clinical Anatomy Learning Centre at Lancaster University.
This article is republished from The Conversation under a Creative Commons license. Read the original article.
A man named Rike cured cancer in rats and mice which was proven and then he went on to prove it in humans using sound frequencies to explode the virus causing cancer. The AMA and specifically a shrew (incorrect spelling there kids) sought to buy the the patent on the device because he knew this would render a giant amount of medical/financial gain to zero but he refused. He was driven into bankruptcy and alcoholism and death by the AMA.
Big pharma love you more…..get that stab.
It’s the same across all fields and trades. People are just not focusing and paying attention to details. Doctors are human, they get lazy and lose focus too. We live in a business world where people cant read and comprehend past a paragraph in an email. A world where leaving a voicemail is almost an insult and people just call back based on seeing the number that called them and cant be bothered to listen to the voicemail so they are prepared for the forthcoming conversation.
Seems like most everyone is out of focus and no longer works to treat others the way they would want to be treated. Whether its a building contractor, or a surgeon.
I have to say, I recently had surgery and the surgeon marked what side he was working on with permanent marker before surgery. How are other surgeons not doing this? Mine spoke with me and verbally confirmed what side we are working on before he marked it. Seems like that should be standard “operating” procedure.
Demand for healthcare is increasing due to increasingly unhealthy lifestyle choices, especially those related to the consumption of processed foods. Few people realize that medicare is the single biggest cost to the American taxpayer. It literally is destroying our economic foundation.
At least we have a diverse community of doctors and we’re being super inclusive!
It makes perfect sense to me. Take a person that cannot read at a third grade level and put them in Med school.
Surgeries are performed by a team of professionals. You cannot live without a liver. You can excise part of it or replace it with a donor transplant but you have to have one. It’s the largest internal organ, weighing between 3-3.5 pounds. The spleen is one of the smallest, weighing 226 grams or about 1/2 a pound.
How on earth did nobody in that room speak up when that surgeon removed his liver?
The entire Western medical industry exposed themselves to be ‘killers for hire’ during the covid scam.
Whether by willful ignorance or with malice and forethought, the entire medical community are mass murderers. And that’s exactly what Western governments want them to be.
So, just as with covid treatments and injections, doctors should be avoided at all costs.
Emergency medicine is for emergencies, only. They know nothing about health or care.
250,000 People Died from Med Mal Last Year . I avoid doctors like the plague that they are !