'Never events:' State releases latest tally of deaths, items left behind during surgery

In 2012, two people had the wrong body parts operated on in Maine, 14 had something left behind inside them after surgery and 36 died in a hospital setting of something they weren't expected to die from.

A new state report shows those numbers are mostly down from the year before: Two wrong parts, 16 somethings and 61 unanticipated deaths.

Since 2004, the Department of Health and Human Services has reported to the Legislature each spring on "sentinel events" — errors, serious injuries and accidents in the state's hospitals, free-standing surgery centers, kidney centers and intermediate care facilities. Nursing homes aren't included in the count.

Maine is one of 28 states that track these figures, hoping to learn from them.

"It used to be called 'never-events' ... because people felt like they should never happen," said Jill Rosenthal, senior program director for the National Academy for State Health Policy, which has an office in Portland.

Facilities have 24 hours to call a state Sentinel Event Hotline after a mishap and 45 days to share a "root cause analysis" — how it happened, why it happened and what's in place to keep it from happening again.

Trends may call for more education and repeated faulty products for a report to the manufacturer, said Joe Katchick, the public health nurse supervisor who oversees the annual report in DHHS' Division of Licensing and Regulatory Services.

"We're looking for those issues that we can share throughout the state of Maine for patient safety," he said.

'Zero is the target'

2012 saw 146 reported sentinel events. The top five issues: Unanticipated deaths (36), deaths or serious injury from falls (26), unanticipated transfers (24), pressure ulcers (15) and retained foreign objects (14).

In the case of unanticipated deaths, "you go in for a simple procedure, you end up dying from something that's not related to the initial diagnosis or treatment that you went in for," Katchick said.

Pressure ulcers happen when the skin breaks down from positioning. In a hospital setting, he said, that could happen to someone immobilized in a body cast after a serious accident.

Unanticipated transfers involve a patient at one facility unexpectedly moving to another facility, often to a larger hospital or trauma center, for something unrelated to the initial visit, Katchick said.

Retained foreign objects are items discovered inside patients after surgery.

"That's on the upper end of the numbers, unfortunately," he said. "A lot of people think big glaring items — scissors or a hemostat," but that's often not the case.

Items can range from sponges to instruments.

The country started paying more attention to sentinel events after the 1999 report "To Err is Human" by the Institute of Medicine, Rosenthal said. It "put a number to" the problem and recommended each state start a tracking system.

Fifteen already had them in place.

Maine was "in the wave of states that started addressing this issue when it was more clear what it was," Rosenthal said.

The original sentinel events bill was sponsored by then-state Sen. Anne Rand, a Portland nurse, in 2001.

"It came from a consumer complaint that wanted to set up a program like this," said Sandra Parker, vice president and general counsel at the Maine Hospital Association. "It's not a report card program; there are lots of those, hundreds of metrics you can look at hospitals and physician practices, but this one, the whole idea is to improve the quality of health care and improve safety."

She believes it has.

Those wrong sites and retained objects happened against the backdrop of 156,698 surgeries performed at Maine hospitals in 2012.

Small figures, "although zero is the target," Parker said.

Her group plans an educational event to members around sentinel events this fall.

All 41 hospitals in the state are required to participate in the program, although 2010 was the only year all 41 actually did.

Only 34 Maine hospitals had at least one event report last year.

"We're hoping everything is being reported," Katchick said.

Since hiring a staffer six months ago, "now we're being able to work on the database, we're going out into the field doing education and audits, and that's where we're hoping to capture, trying to make sure we're not missing anything," he said.

Cases are scrubbed of any identifying information before they're tallied on the annual report and shared with the public or other hospital facilities. State statute keeps details confidential, though there's some argument against that.

Shenna Bellows, executive director of the American Civil Liberties Union of Maine, looked at sentinel event reporting last year when she chaired the Public Records Exceptions Subcommittee of the state's Right to Know Advisory Committee.

"If the public knows what types of sentinel events occur and where they occur, then the public can make more informed decisions about their health care services," Bellows said. "This is an issue we will continue to monitor because we believe in the public's right to know."

Patient advice

It's difficult to compare sentinel events across the states. In New Hampshire, reporting is entirely confidential and nothing, not even numbers, is reported out, according to a state official.

Massachusetts, which has tracked hospitals and surgery centers since 2008, calls them "serious reportable events." In a June report, that Department of Health and Human Services projected 324 incidents for 2012, twice as many as Maine, with injuries or deaths from falls (152) topping the list. It also includes "wrong patient surgery," counting four.

Maine hasn't had any over the nine years, Katchick said.

Rosenthal said the release of any information is helpful so would-be patients "know the kinds of questions to ask and the kinds of things to look for."

"You know wrong-site surgery is something that shouldn't happen but does happen," she said. "Just by knowing that I think a consumer can be informed enough to have a conversation with their physician: 'Is the site marked appropriately?' It (also) helps you understand as a patient why you might get asked five times if you're allergic to a medication."


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Gary Corkum's picture

Wrong surgery CMMC

My daughter was misdiagnosed at CMMC would not surprise me if most of the screw up's happened at CMMC. They removed her appendix and botched the operation causing her to develop appendix cancer. My personal experience there is that the staff is disrespectful and made me feel like they were "better" then me. I would rather die then to be uncared for at CMMC. Take me to ST Mary's where at least I feel cared for by people that truly care for you no matter what your background!

Wendi Ward's picture

That is horrible. I have

That is horrible. I have worked for both hosoitals and have delt with both hospitals for care for my children. I can say they both have their good and bad points. St. Marys diagnosed my daughter with anxiety...when she had pericarditis!

Wendi Ward's picture


I'm surprised this number is so low. I work in healthcare and I see a lot of these going on. Healthcare needs a overhaul, the way things are relayed from patient to nurse to dr..it's like a bad game of telephone.... I do think now that we take a time out in the OR and the counting of instrument before and after surgery have helped a lot. However I'm not such a fan of asking the patient to mark the point that is being operated on. If an older person, has dementia, it could be undiagnosed..but that patient might get confused when asked to mark the spot. I've see people get their left and right sides mixed up. I'm glad to see the numbers are better, but we still have a long way to go. I would also like to know what hospitals and what the events were.

Jim Cyr's picture

Never events ??

Which hospitals ??

Mark Elliott's picture

Curious but.....how many died

Curious but.....how many died of gunshot wounds?

Wendi Ward's picture

Sentinel events don't include

Sentinel events don't include gunshot victims. A sentinel event is when you die at the hospital of something other than the reason your in the hospital. You go in to get your appendix removed and you die from something totally unrelated and unexpected.

Mark Elliott's picture

It was sarcasm....we average

It was sarcasm....we average half that in firearms homicides and the left wants to ban guns and strip us of our right to defend ourselves. Media is all over it, night and day because it sells.......Sentinel deaths are double and we get one article, once a year. You are more likely to die from negligence in the hospital, then from a firearm in someone else's hands........


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