In medical parlance, "never events" are medical errors that should never happen. However, as we are about to find out, they do happen more than doctors would probably like to admit.
As of 2011, 29 incidents are classified as never events. They include but are not limited to patients falling off hospital beds, doctors using the wrong procedures for treatment, doctors forgetting surgical equipment in the bodies of patients, and doctors performing surgeries on the wrong patients.
Here, we will focus on never events that happened during surgery.
10. 17-Year-Old Gets Wrong Heart And Lungs During Transplant
In 2003, 17-year-old Jesica Santillan experienced what should be the worst never event incident that has ever happened. Three years earlier, she had been smuggled into the US by her parents, who wanted her to get medical treatment for her failing heart and lungs. Philanthropist Mack Mahoney read about her story in a newspaper and footed her medical bills for surgery at Duke University Hospital.
Santillan underwent the surgery on February 7, 2003. But it only worsened her situation because the doctors used organs from a donor with the wrong blood type. The donor had blood type A while Santillan had blood type O. They are incompatible.
Santillan's body rejected the organs as she suffered a series of seizures and ended up on life support. Two weeks later, she underwent a second surgery. This time, the organs were of a compatible blood type. Although they worked well, it was too late. Santillan had suffered irreparable brain damage and was put on life support for some time. Eventually, she was taken off it.
At the time of her death, there were about 200 people in the US requiring donors for a heart-lung transplant. Santillan was supposed to be at the end of that list. But she was allowed to go to the front of the line because her situation was dire.
The medical error resulted in two sets of organs wasted. It also reduced the chances of survival for others awaiting surgery because it deprived them of the much-needed organs.
9. 83-Year-Old Woman Undergoes Heart Surgery For A Respiratory Infection
Staff at Mediclinic Kimberley Hospital in Johannesburg, South Africa, committed a never event after they made an 83-year-old woman undergo a heart surgery intended for another patient. The woman was Rita du Plessis, and she was at the hospital to have a respiratory infection treated.
Du Plessis and another patient requiring heart surgery had the same physician. Their doctor told a surgeon to take the other patient into the operation theater, but the surgeon mixed up the names and took du Plessis instead. After she underwent the heart surgery, her family was even contacted and told that it had been a success.
Staffers only realized their error after thephysician, who had been looking for du Plessis, informed them that they hadoperated on the wrong patient. The physician later called du Plessis's familyto explain the situation and apologize. The hospital did not charge her for thesurgery.
8. Woman Loses Breast To Cancer She Didn't Have
In 2018, Kenyatta National Hospital in Kenya made the news after a patient underwent a brain surgery intended for another patient. Both men were wheeled into the hospital unconscious and kept in the same ward. However, they somehow ended up with each other's identification tag and the wrong one ended up in the operating theater.
The patient who required surgery had a blood clot in his brain, while the other simply had a swollen head. Surgeons wheeled the patient with the swollen head into the operating theater. But they didn't realize that they had the wrong man until two hours later when they didn't find a blood clot in the brain.
