Surgical Never Events: A retrospective study in Iranian Hospitals

Abstract

Background: Never event is an unintentional injury or complication that increases the length of hospital stay, disability at the time of discharge or death due to improper health care management. Adverse events are potentially preventable in terms of patient injury, increasing the length of hospital stay, and increasing health care costs. Due to the importance of the subject, the present study was conducted to investigate the factors related to adverse surgical events in Iranian hospitals in 2020.
Methods: This cross-sectional study (descriptive-analytical) was conducted to determine the factors associated with adverse events related to surgery in Iranian hospitals. All reports entered in the unwanted events registration system related to codes 1, 2, 3 and 4 of unwanted surgical events from March 2018 to March 2021 were included in the study.
Results: The results showed that the rate of surgical Never events in Iranian hospitals is about 0.006%. The highest incidence of unwanted surgical events in error code 4 (leaving any device including gas, scissors, pliers, etc. in the patient's body) with 63.7% and the lowest incidence of adverse surgical events in error code 2 (performing surgery incorrectly on another patient) was 4%.
Conclusions: The findings of the present study show that the rate of unwanted surgical events in Iranian hospitals is lower than the global average. Lack of a precise framework for job descriptions and responsibilities, failure to use instructions, and lack of decision support systems are all factors in the occurrence of adverse surgical events.