Never events continue to occur in young surgical patients: Evidence from the Nationwide Inpatient Sample, 2003-2012

Background: “Never events” are preventable medical errors considered so grievous that they should never occur. In surgical patients, these never events include operating on the wrong patient or wrong body part, performing the wrong operation, and inadvertently leaving a surgical item in the body during surgery. Recent evidence suggests that never events continue to occur in surgical patients despite process improvement efforts. Little is known, however, about surgical never events in young patients.

Methods: Utilizing the 2003-2012 Nationwide Inpatient Samples (NIS; renamed the National Inpatient Sample in 2012 to reflect changes in sampling approach) [Healthcare Cost & Utilization Project (HCUP), Agency for Healthcare Research & Quality], we sought to characterize the frequency of and risk factors associated with never events in patients under the age of 20. Never events were identified in the NIS using International Classification of Diseases, 9^thRevision, Clinical Modification (ICD-9-CM) external causes of injury code. Risk of never event was evaluated with a multivariate logistic regression model which included year, race, gender, census region, hospital type, procedure type, and obesity status. All analyses utilized trend sampling weights provided by HCUP.

Results: Over 45 million young patients underwent a surgical procedure between 2003 and 2012 (mean age: 5.35 years, standard deviation: 15.78). A total of 441 of these young patients experienced a never event. The majority of these never events were retained surgical items (88.56%); however, wrong patient (1.00%), wrong body part (5.04%), and wrong procedure (5.41%) operations also occurred during the study period. Between 2008 and 2012, the risk of never events was significantly higher than in the index year (2003), reaching its highest level in 2011 (OR: 3.79 [2.25-6.40]). Compared to children under the age of 4, patients between ages 9-12 years (OR: 3.98 [2.94-5.40]) and 12-16 years (OR: 3.54 [2.65-4.73]) were at the greatest risk of experiencing a never event. Compared to all other surgeries, young patients undergoing operations of the integumentary system (OR: 3.11 [1.93-5.01]) and urinary system (OR: 3.04 [2.45-3.79]) were at the highest risk of experiencing a never event.

Discussion: Despite efforts to eliminate these egregious medical errors, never events continue to occur in pediatric surgical patients. Continued vigilance and process improvement is needed to eliminate never events in young patients undergoing surgery. Caregivers should be particularly concerned with – and guard against – wrong patient, wrong part, and wrong procedure surgeries, as these events are particularly disturbing and preventable.