United Kingdom’s National Health Service Reports on “Never” Events

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They are deemed “never” events because they are such egregious mistakes that they should never occur. Yet the UK’s National Health Service is reporting that 148 such events occurred in a six month span this year between April and September. The “never” events include the following: the wrong patient receiving heart surgery, patients given overdoses and one woman who had a fallopian tube removed instead of her appendix. In one incident, a drill guide block was left inside a patient’s body. The figures also showed that 37 patients had the wrong part of their body operated on or treated. This included four operations on the wrong tooth, an operation on the wrong toe, one patient who had an injection in the wrong eye and one case where a woman had the wrong fallopian tube removed during an ectopic pregnancy, probably rendering her infertile. Another woman had a fallopian tube removed instead of her appendix. These errors occur most often due to a communication breakdown where standard procedural checklists are not followed.

Mark Abramson
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