Surgeons have an encouraging term for their mistakes: "never events," because they should never happen. Yet they do, with startling frequency.
At least 4,000 times a year in the United States, surgeons leave a sponge or instrument inside a patient, perform an incorrect procedure, or operate on a wrong body part or even a wrong patient, according to a recent study from the Johns Hopkins University School of Medicine.
That estimate is probably low, based as it is on malpractice claims, because many errors don't turn into legal actions. Some go undetected altogether.
In one in 15 cases, the mistake leads to a patient's death.
Why can't preventable mistakes be prevented? Studies have long established the value of operating-room checklists and other simple strategies such as marking the surgery site with indelible ink. Evidently, they aren't universally employed. Some surgeons may think that they take too much time, or that it's enough to rely on their own caution and competence.
To change that, what's needed is an accurate, public accounting of surgical errors. As Martin Makary, the leader of the Johns Hopkins study and the author of the new book "Unaccountable," said, "To fix a problem, you need to measure it."
Hospitals' own voluntary reporting systems miss most errors - in fact, almost all of them, according to a study of "adverse events," a term that also includes unanticipated but less easily preventable problems such as infections. Software from the federal Agency for Healthcare Research and Quality can screen patient discharge records for "patient safety indicators" (complications), and states and Medicare and Medicaid use it to gauge hospitals' performance. This approach isn't much better, though: It fails to account for nine out of 10 adverse events.
Far more effective, the study found, is third-party review of medical charts. The idea is to find "triggers" that indicate something went wrong - a change in surgical procedure, say, or a postsurgical patient's being returned to the operating room or sent to the intensive-care unit. When a trigger is spotted, the case is investigated. In the adverse-events study, the Institute for Healthcare Improvement's Global Trigger Tool detected more than 90 percent of hospitals' adverse events.