When it comes to surgical errors, human behavior plays a major role. There are 628 human factors that contribute to 69 different surgical errors, also known as “never events”, according to a new Mayo Clinic study published in the journal Surgery.

Mayo Clinic researchers used human factors analysis, which is a system that was developed to investigate military aviation accidents, and uncovered the 69 never events among 1.5 million invasive procedures that occurred over the span of five years and the reasons behind them.

The never events they identified included 24 cases of performing the wrong procedure, 22 cases of performing surgery in the wrong part of the body, five cases of putting in the wrong implant and 18 cases of leaving an object in the patient after surgery. Even though the events are significant, none resulted in a fatality.

Dr. Juliane Bingener, senior author of the study and gastroenterologic surgeon at Mayo Clinic, believes that even though medical teams are “highly skilled and motivated,” preventing never events is still elusive. She stressed that hospitals need to ensure that the team is vigilant and encourage them to alert each other about potential issues.

The researchers categorized the never events into four categories that include dozens of human factors.

Preconditions for action: inadequate hand-offs, distractions, overconfidence, anxiety, mental exhaustion and poor communication.

Unsafe actions: breaking rules or failing to understand.

Oversight and supervisory factors: staffing deficiencies and planning issues.

Organizational influences: issues with the organizational culture and operational process.

To prevent these never events, many protocols can be implemented including The Joint Commission health care quality organization’s Universal Protocol, team briefings before surgery begins, a pause before the first incision and debriefings using a safety checklist recommended by the World Health Organization. Mayo Clinic has implemented a sponge-counting system that puts bar codes on the sponges to keep track of them.

Fortunately, never events are not very common — the study found that it occurs in about 1 in every 22,000 procedures. In addition, almost two-thirds of the events happened during relatively minor procedures including anesthetic blocks, line placements, interventional radiology procedures, endoscopy and other skin and soft tissue procedures.

But it’s still an important issue that needs to be addressed. "The most important piece is the patient perspective,” Bingener said in a statement. “You don't want a patient to have to experience a never event. The breach in trust that happens with that is the most important part.”

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