Each accounted for 8% of the total 1,411 reported sentinel events, ranking second and third respectively. Both errors saw increases from 2022, with wrong surgeries up by 26% and unintended retention by 11%. These errors, often termed “never events,” indicate the need for improved procedural and organizational practices within surgical teams.
Wrong Surgeries:
Wrong surgeries, including procedures performed on the wrong site or patient, or unintended procedures, were reported 112 times. These errors led to severe temporary harm, unexpected additional care, or permanent harm. The primary causes were insufficient timeout procedures, task fixation, and poor team communication.
Unintended Retention of Foreign Objects:
110 reports of unintended retention involved items like sponges, guide wires, and fragments of surgical instruments. These errors frequently caused severe harm and additional care. Contributing factors included poor adherence to counting policies, lack of shared understanding, and communication failures.
Preventative Measures:
The Joint Commission’s Universal Protocol, involving verification, site marking, and final timeout, is a key strategy to prevent wrong surgeries. Other strategies include using technology like radiofrequency identification (RFID) to prevent retained sponges and enhancing communication among surgical teams. A computer-aided diagnosis (CAP) system has shown promise in detecting retained items post-surgery.
The article emphasizes the need for strict adherence to protocols, improved teamwork, and the integration of technological solutions to reduce these sentinel events, making them truly “never events.