When I started working at the hospital, I heard mentions of “never events” here and there, but I was never formally taught what they were. Of course, one could intuitively predict the types of instances that are classified as “Never Events.” I figured I would go ahead and post them up here and discuss a few which I’ve encountered thus far during my training. Never events are considered serious but preventable incidents that occur in healthcare because the available preventative measure where not considered.
- Wrong site surgery (excluding wrong site anaesthetic blocks) – This is actually one that I pay close attention to. There has been an incidence a few weeks ago where a pregnant patient was going to undergo a parathyroidectomy on her left side, and she was consented for the left side, but the program that listed the operations had her down for a right parathyroidectomy. I managed to rectify that issue before the patient went into the operating room. There was another instance, again to do with technical issues, where the patient was consented for a procedure in her left breast, and all correspondence and imaging identified the lesion in the left breast, but the OR program had the right breast listed.
- Wrong implant/prosthesis
- Retained foreign object postoperation
- Wrongly prepared high-risk injectable medication
- Maladministration of potassium-containing solutions
- Wrong route administration of chemotherapy
- Wrong route administration of oral/enteral treatment
- I.V. administration of epidural medication
- Maladministration of insulin
- Overdose of midazolam during conscious sedation
- Opioid overdose in an opioid-naïve patient
- Transfusion of ABO incompatible blood components
- Transplantation of ABO incompatible organs as a result of error
- Misplaced naso or oro-gastric tubes – This is why I order a chest X-ray for every patient that gets a naso-gastric tube. The amount of patients I see who get an NG tube placed and then commence with feeds before radiographic confirmation baffles me. I mean, I haven’t witnessed any incidences where the NG tube was in the wrong place, but I would be wary to commence feeding before being absolutely certain.
- Wrong gas administered
- Failure to monitor or respond to oxygen saturation
- Air embolism
- Maternal death because of post-partum haemorrhage after elective Caesarean section
- Misidentification of patients
- Inappropriate administration of daily oral methotrexate
- Suicide using non-collapsible rails
- Escape of transferred prisoner
- Falls from unrestricted windows
- Entrapment in bed rails
- Severe scalding of patients
At this stage of my training, I am not solely responsible for many of these yet, and I always discuss things I’m not comfortable with with my seniors, but I hope I that I am NEVER part of a Never Event.
Today was pretty uneventful for the most part, so here are a few pictures.
And then the excitement of the day happened…
It was probably around 20:00, and we were waiting for my BF’s dad and his friend to come home so we could all eat dinner. Only, he had gone off with some old childhood friend, had been gone for several hours, and no one had any idea how to reach him! So I’m there thinking that everyone’s worrying over nothing – I mean, two old men are out, catching up with friends they haven’t seen in years.
They called everyone they knew. They even went all old school and whipped out a phone book to look up phone numbers. Finally they reached someone, and we’re told they they were at the hospital…
My BF’s dad had some nausea and vomiting, which concerned his friends, so they brought him to the hospital. It turned out to be nothing too serious. Just some exhaustion. But I guess everyone was right to worry. At least nothing serious happened. We went home after discharge, and that was pretty much my night…
I’ve always known that my stomach wasn’t able to handle quite everything. As a kid, riding the bus during school field trips would cause me to rush to the bathroom once we reached our destination. I managed to get over that, but the sight of certain things still causes my stomach to churn and the partially digested food I’ve just eaten begins to make its way back up the wrong tube. For instance, people’s fresh boogers and puke still make me want to… well, puke.
The point of this is a recent event at the hospital. I have yet to work with kids, and I’m lucky enough that I don’t have to deal with too many of them. However, one day as I was changing patients, there was a child playing in the playroom with his family. He happened to regurgitate everything he ate for breakfast. No problem, I thought. There’s no need to call housekeeping – I’ll just grab some paper towels and help his family clean it up. Oh boy was I wrong. As I inched closer and closer to the spew on the floor, I felt my stomach rumble. I dropped some paper towels on the floor and slowly bent over to scoop everything up. My eyes began to fill with tears. My stomach began to rumble a bit more. And then I felt it – my gag reflex had been initiated. No – lucky I didn’t add to the mess. I removed myself from the scene and ended up calling housekeeping to clean up what remained of the mess. With my eyes still glistened over, I told the family that I thought I could stomach helping to clean up, but I couldn’t.
This leads me to wonder what kinds of bodily fluids and messy spills I’ll have to handle during medical school. I mean, I know I can handle the sight and smell of blood, but the human body contains a lot more fluids and other various excretions that can be expelled from the body at any time. Will I be able to maintain my composure? Maintain my recently digested meals? I guess I’ll just have to find out when the time comes and hope for the best.
** I’m attempting to post more often than normal, but I’m finding it difficult. And the picture above was taken while at Wasaga Beach a few weekends ago. **