Near Misses, Never Events, and Just Plain Scary Cases

PROGRAM DESCRIPTION: The wrong ear was implanted. A needle was left in the child’s neck. A man in septic from retained nasal packing after sinus surgery. A woman’s face is burned after a fire fueled by prep solution. A healthy baby coded in recovery after tympanostomy tube insertion. Otolaryngologists believe these events could never happen in their operating room. Yet never events such as wrong site surgery, wrong patient surgery, unintentional retained foreign objects, operating room fires, or immediate postoperative death in a healthy patient are more common than they should be in head and neck surgery. Even in the absence of a distinct never event, these factors periodically align to result in near catastrophic patient outcomes. Such events are caused by a myriad of interacting elements including systems deficiencies, human factor or decision-making errors, and team failures.
Near misses, sentinel events and horrific complications affect patients and families often irreversibly. They also increasingly draw scrutiny to surgical practices and systems, surgeon technical competencies, and evidence-based decision-making. In the last decade numerous programs or hospitals have been gravely impacted by the failure to prevent, recognize, or respond to major surgical errors or complications. In this audience-interactive panel, we present real-life cases that went wrong, how these problems were addressed, and potential solutions to avoid or mitigate these crises in the future. Through these case presentations we emphasize key principles of root cause analysis, health system safety, institutional safety culture, and quality improvement interventions to address these types of events in otolaryngic surgery.

OUTCOME OBJECTIVE 1: Recognize the wide range of unexpected catastrophic adverse events that can occur in otolaryngology-head and neck surgery through actual case discussions and storytelling

OUTCOME OBJECTIVE 2: Learn specific interventions that may be able to reduce the likelihood or mitigate these never and near miss adverse events

OUTCOME OBJECTIVE 3: Highlight system and human factors that lead to never events and outline performance improvement strategies to mitigate occurrences.

BACKGROUND STATEMENT: The success of medicine is multifactorial and typically requires making sense of complex situations within uncertainty. This presentation will use real stories of adverse events to elucidate how adopting these organizational characteristics can impact OHNS.