"Physician compliance with a complete and accurate time out
remains an area for opportunity," says Mr. Polito, tactfully articulating
the challenge.
It's anyone's guess as to how or whether any of the concerns read-
ers express figure into the significant number of never events they've
witnessed.
As noted, 44% of respondents say their facilities have had them.
Considering that another 10% say they might have but they're not
sure, fewer than half of respondents are left to say with some cer-
tainty that they haven't.
The events recounted by respondents cover a wide array, including:
• Wrong-site surgery. Spine surgery at the wrong level, wrong-site
hernia repair, wrong tooth extraction, wrong cataract lens implant and
wrong breast injection.
• Wrong-side blocks. Eye block and regional blocks.
• Retained objects. Tip of a drill guide and a lab sponge.
• Burns. Wrong prep leading to a corneal burn.
Several respondents say that new policies and procedures were put
into place after those events occurred, and that they haven't happened
since.
As clear as it is that patient safety isn't what we'd like it to be on a
national level, our survey makes it equally clear that the vast majori-
ty of administrators, physicians and staff care deeply and work tire-
lessly to keep their patients safe. But the challenges are stubborn
and varied, and our survey also reinforces the realization that a diffi-
cult journey lies ahead. It's often noted that the aviation industry
found itself at a crossroads some years back, and responded by
implementing a series of mechanical and interpersonal measures
that have made air travel a model of safety.
Will it take something similar for patient safety to reach the same
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