When “Never Events” Happen ... All the Time in Hospitals

The following is an excerpt from my book "The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation ."

Many healthcare professionals still don’t feel safe speaking up about mistakes. One study estimates that about 40 wrong-site or wrong-side surgeries occur each week across the U.S., but according to The Joint Commission, only 68 wrong-site surgeries were reported in 2020. Healthcare experts agree that incidents and harm of all types are underreported by a large margin, but by how much? One estimate suggests only 3 to 5% of errors are reported.[i] That indicates it’s still not safe to speak up. Or they feel like it’s futile. Or both.

Healthcare has optimistically started referring to mistakes like these as “never events.” They should never happen; they are completely preventable. The oft-prescribed solution to wrong-side, wrong-site, or wrong-patient surgeries is the checklist, as introduced in Chapter Four. To prevent mistakes, surgical teams should always take steps that create a positive confirmation that they have the correct patient on the table for the correct procedure. The surgeon marks or signs near the surgical site with the patient’s confirmation while they are still awake.

A combination of these practices, including a timeout, is often referred to, also optimistically, as the “universal protocol,” meaning it should be done everywhere, every single time. If the protocol were truly universal, we’d be closer to the goal of never making these mistakes.

Again, it’s more about the culture than the checklist. At a Wisconsin health system, former CEO Dr. John Toussaint recalls one of their hospitals had four wrong-site surgeries over an eight-week period in 2004. Problems “slipped under the radar” of senior leaders because “everybody simply kept quiet.”[ii] Eventually, through the medical peer-review process, then-president Kathryn Correia was informed of the mistakes. She immediately shut down the surgical suites, meaning no more procedures until they had a plan to “ensure the safety of every patient.” The surgeons agreed to have an independent auditor present at every surgery to lead the timeout, to ensure the universal protocol was followed.

As Toussaint wrote,

“There was no upside to reporting errors in our shame-and-blame culture, so most opportunities for learning and improvement were lost.”

Correia realized that she needed to improve the culture-change efforts.

Today, hospitals make mistakes related to surgical procedures:

●????? Not doing the timeout or checklist (or just going through the motions to check the box)

●????? Assuming the timeout or checklist isn’t needed because it was skipped a few times and didn’t lead immediately to patient harm

●????? Not speaking up about a surgeon skipping the timeout or checklist (because they didn’t feel safe)

●????? An executive not shutting down operating rooms to investigate after becoming aware of mistakes, whether they lead to harm or not

Getting to “never” also requires a culture that helps anybody in the operating room feel safe to speak up to raise a concern, even if that delays or stops the work. Toyota has this culture, in circumstances where the stakes are generally much lower. Some health systems perform better in getting closer to “never events” actually never happening, not because of luck or the surgeon’s skill, but because of better systems and cultures of higher psychological safety .

[i] Classen, David, et. al., “An Electronic Health Record–Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement,” Health Affairs, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.0728

[ii] Toussaint, John, MD, On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry (Cambridge, MA, Lean Enterprise Institute: 2010),