A 70-year-old man from Alabama recently died at a hospital in Florida when a surgeon mistakenly removed his liver instead of his spleen.
Author
Adam Taylor
Professor and Director of the Clinical Anatomy Learning Centre, Lancaster University
This type of medical error is known as a "never event" because it should never have happened. Unfortunately, they happen all too often.
Never events range from the wrong organ or side being operated on, the wrong prosthesis (such as hip joints) being inserted, to foreign objects (typically surgical instruments and swabs) being left inside the patient.
In the UK, provisional NHS data shows that between April 2023 and March 2024, there were 370 never events. In the three years prior to that, the figures were, in reverse order, 384 (2022-23), 407 (2021-22) and 364 (2020-21). So, roughly, one of these events occurs each day. Given the number of procedures performed daily by the NHS, these figures are impressively low. Although I suspect that would be cold comfort for anyone affected by one of these often life-changing errors.
In the US, there has been a recent increase in never events, with 1,440 in 2022 and 1,411 in 2023. Before this, never events were less than 1,000 a year. In 2023, 18% of these events resulted in the patient dying and 8% in permanent harm or loss of function.
What are the most common errors?
Considering the man from Alabama, it is difficult to see how a surgeon might confuse the spleen and liver given that the basics of anatomy are taught early in medicine. And then the subsequent years of postgraduate training see doctors focus on areas of their speciality, such as general surgery, orthopaedics, neurology and others, which further reinforces their knowledge of their chosen speciality region.
Many surgical careers take at least 15 years of medical training to achieve in the UK, and similar lengths of time in the US and elsewhere. However, it is well recognised that where these errors take place, they are often multifactorial.
The most common errors are seen on the wrong side of the body. Humans are symmetrical in many ways, with pairs of various organs, so confusion over the left and right happens.
In urology, studies have shown that in over 10% of cases clinical letters fail to mention the diseased side (8.7%) or they mention the wrong side (3.3%). And sometimes radiology images are placed on the screen the wrong way around. These things can lead to patients having their healthy kidney removed rather than the diseased one.
Other paired structures that are often removed from the wrong side are testicles, which can leave patients infertile.
Similar surgical errors have affected women's fertility, with surgeons removing the wrong uterine (fallopian) tube. In other errors, healthy ovaries have been removed or, at least in one case, removed in error (it should have been the pregnant woman's appendix that was removed), sadly leading to the patient's death.
A study from the US suggests that the most likely surgical speciality to perform wrong-site surgery was orthopaedics (35%), followed by neurosurgery (22%) and then urology (9%).
Others have confirmed orthopaedics as having one of the highest rates of wrong-site surgery - 21% of hand surgeons confirmed they'd operated on the wrong site.
Sometimes other circumstances, such as mistaken identities and clerical errors, result in death. For example, a hospital in the Bronx, New York, turned off the life support of the wrong patient. In another tragic case, a 17-year-old girl was given a donor's heart and lungs, but they were blood-group incompatible. She died shortly after.
These types of errors are rarely published in medical journals, probably due to the legal implications. So the media is often the first source to detail these errors. However, media reports tend to contain limited relevant medical information that might enable wider lessons to be learned from these cases.
Never events have huge implications for patients and their families, and many of them result in significant payouts. The cost of settled claims paid out by the NHS in 2015-20 was over £17 million. And, globally, between 1990 and 2010 claims were over US$1.3 billion (£990 million).
Safety checklists
There is continuing progress towards eliminating never events. In 2008, the World Health Organization (WHO) launched the surgical safety checklist, which was adopted by the NHS in 2009.
Similar protocols have been used in the US since 2004.
These sorts of protocols bring consistency across healthcare providers, and shortly after the WHO's checklist was introduced, it was shown to reduce post-operative complications and deaths by 36%. However, as the statistics on never events show, there is still plenty of room for improvement.
As the demand for healthcare increases, systems have to adapt to ensure patient safety is not compromised. Given that so much appears to be linked to human factors, appropriate staffing, workload and welfare will all be of paramount importance.
Adam Taylor does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
