7 Essential Facts About Surgical Never Events in New York

Part of: Surgical Errors →

7 Essential Facts About Surgical Never Events in New York

When you or a loved one needs surgery, you expect the highest standard of care. You trust medical professionals to perform the correct procedure on the right patient and body part. Unfortunately, serious medical errors known as “never events” continue to occur in New York and across the nation. These are preventable mistakes that should simply never happen in a healthcare setting. Understanding these events, why they persist, and what steps you can take if affected is crucial for protecting your health and your rights.

This article aims to provide clear, compassionate guidance on surgical never events in New York. We will explore the types of errors, their disturbing frequency, the underlying causes, and the significant impact they have on patients. Also, we will outline your legal rights and the essential steps to consider if you or a family member suffer harm from such a preventable surgical mistake.

1. What Exactly Are Surgical Never Events?

Surgical never events are precisely what the name implies: medical errors so egregious and preventable that they should never occur during surgery. The term “Never Event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), to describe particularly shocking medical errors, such as wrong-site surgery. These events are clearly identifiable, serious in their consequences, and typically preventable. The NQF has since expanded this list to include 29 events grouped into categories like surgical, product or device, and patient protection.

Why it stands out: These are not minor complications or accepted risks of surgery. Instead, never events represent fundamental failures in patient safety protocols that can lead to severe and lasting harm, permanent injury, or even death. The Centers for Medicare and Medicaid Services (CMS) stopped reimbursing for costs associated with many preventable errors, including never events, as early as 2009. This policy highlights the national recognition that these errors are unacceptable.

2. The Disturbing Frequency of These Preventable Errors

Despite widespread awareness and established safety protocols, surgical never events occur with alarming regularity. Estimates suggest that wrong-site surgery happens around 40 times per week in hospitals and clinics across the United States. Another study estimated that more than 4,000 surgical never events occur annually nationwide. These numbers underscore a persistent challenge within the healthcare system.

Why it stands out: In New York State, the Department of Health tracks adverse events through the New York Patient Occurrence Reporting and Tracking System (NYPORTS). From 2018 to 2022, NYPORTS recorded 570 occurrences coded as “Wrong side/wrong patient/wrong procedure”. While these incidents are considered rare on an individual basis, their collective occurrence indicates a systemic problem that demands ongoing vigilance and improvement. Research supported by the Agency for Healthcare Research and Quality (AHRQ) estimates that wrong-site surgeries occur at a rate of approximately 1 in 112,000 to 1 in 113,000 surgical procedures nationally.

3. Wrong-Site Surgery: A Persistent Challenge

Wrong-site surgery, where an operation is performed on the incorrect body part or side, remains a significant concern. This category includes wrong-side surgery, such as operating on the left knee instead of the right, and wrong-level surgery, often seen in spinal procedures where the wrong vertebra is targeted. These errors can lead to unnecessary pain, prolonged recovery, and the need for additional surgical interventions.

Why it stands out: The American College of Surgeons (ACS) and The Joint Commission have developed extensive guidelines to prevent wrong-site surgery. These include verifying the correct patient, site, and procedure with the patient and surgical team, marking the operative site, and conducting a “time-out” before incision. Despite these protocols, wrong-site surgery was the third most frequently reported sentinel event in 2018, according to The Joint Commission. This highlights that simply having protocols is not enough; consistent adherence is paramount.

4. Wrong-Patient and Wrong-Procedure Surgeries: Unthinkable Mistakes

Beyond wrong-site errors, hospitals and surgical centers sometimes face the unthinkable: performing surgery on the wrong patient or carrying out an entirely different procedure than intended. A patient scheduled for a hernia repair might erroneously undergo an appendectomy, for example. These errors represent profound breakdowns in patient identification and procedural verification processes.

Why it stands out: The consequences of wrong-patient or wrong-procedure surgeries are often catastrophic, potentially causing irreparable harm or necessitating further complex surgeries to correct the mistake. A review of malpractice claims reported to the National Practitioner Data Bank showed that all surgical never events were associated with a 6.6% mortality rate and a 32.9% permanent injury rate. These errors underscore the critical need for every member of the surgical team to remain vigilant and empowered to speak up if any discrepancy arises.

5. Why Do These Critical Errors Still Happen?

Surgical never events are complex issues stemming from a combination of factors. A systematic review of root causes points to human fallibility, breakdowns in communication, inadequate teamwork, and issues with human-technology interaction. Common causes identified by the New York State Department of Health and other experts include communication failures among staff, inadequate preoperative verification, and documentation errors.

Why it stands out: Other significant contributing factors include a lack of standardized protocols, time pressures, fatigue, and insufficient training. Studies have identified various causes of wrong-site surgeries, ranging from scheduling processes to operating-room procedures to organizational culture. Available studies on nursing errors in the operating theater indicate that factors like fatigue, incorrect or insufficient information, and distraction are primary causes. These systemic issues require robust solutions that prioritize patient safety over efficiency alone.

6. The Profound Impact on Patients and Their Families

The impact of surgical never events extends far beyond the physical injury. Patients often endure severe emotional trauma, psychological distress, and a profound loss of trust in the medical system. Many require additional surgeries, face prolonged recovery periods, and may suffer permanent disability. The financial burden can also be immense, encompassing further medical bills, lost wages, and long-term care needs.

Why it stands out: Beyond individual suffering, these errors carry significant financial implications for the healthcare system. A review of medical liability settlements and judgments in the National Practitioner Data Bank for two decades (1990–2010) recorded a total of $1.3 billion in payouts for surgical never events. Wrong-site surgery was associated with a mortality rate, a permanent injury rate, and a mean liability payment of $127,159. Wrong-patient surgery, while less common, had a 7.7% mortality rate, a 26.9% permanent injury rate, and a mean liability payment of $109,648. These figures highlight the devastating human and economic costs of these preventable errors.

7. Your Rights and the Path to Justice in New York

If you or a loved one has suffered harm due to a surgical never event in New York, you have legal rights. New York law allows victims to pursue medical malpractice claims against negligent healthcare providers or facilities. Filing a medical malpractice lawsuit can help you seek compensation for medical expenses, lost income, pain and suffering, and other damages.

Why it stands out: It is important to understand the statute of limitations in New York for medical malpractice cases. For NYC public hospitals, a 90-day Notice of Claim is required, followed by 1 year and 90 days to file suit. For instance, if a foreign object is left in the body, the deadline is one year from the date of discovery. For minors, the statute of limitations may be extended, but typically not beyond 10 years from the malpractice event. Consulting with an experienced personal injury lawyer promptly is essential to ensure your claim is filed within these critical deadlines. New York currently does not limit the amount of compensation a victim can recover in a medical malpractice lawsuit.

Taking Confident Next Steps After a Surgical Error

Experiencing a surgical never event is a deeply distressing experience. It can leave you feeling overwhelmed, confused, and unsure of what to do next. Remember, you are not alone, and you have options. Taking prompt action can protect your rights and help you secure the justice and compensation you deserve.

First, gather all available medical records related to your surgery and subsequent care. These documents are crucial for building a strong case. Next, seek a second medical opinion to fully understand the extent of your injuries and the necessary corrective treatments. Finally, contact a trusted New York personal injury lawyer who specializes in medical malpractice cases. They can review your situation, explain your legal options in plain English, and guide you through every step of the complex legal process, offering the reassurance you need during a challenging time.

Sources

• National Center for Biotechnology Information (NCBI) — Wrong site surgery—where are we and what is the next step?
• New York State Department of Health — The New York Patient Occurrence Reporting and Tracking System (NYPORTS)
• The Aquila Digital Community — Reducing the Risks of Wrong Site Surgery Using the Joint Commission’s Targeted Solutions Tool for Safe Surgery
• The Joint Commission — Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project
• PubMed — Wrong-site surgery: can we prevent it?