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Never Event

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Re: Never Event

#11

Post by whatshisface »

dooglius wrote: post #5
Smaug123 wrote: post #2

The USA list is an interesting conflation of what I think are two distinct classes of error: ones which can be made impossible with the right processes followed correctly, and ones which can't. "Wrong site surgery", "retained instrument post-operation", "infant discharged to wrong person", sure, absolutely agree processes can and should be such that this can literally never happen. On the other hand, "Intraoperative…

Agreed, the no-suicide one is the worst. What process would you even take other than asking "have you had suicidal thoughts?"

It said "while being cared for in a healthcare facility." You can watch people and not leave dangerous objects around the room.

Re: Never Event

#12

Post by dist-epoch »

wrs wrote: post #10
benjijay wrote: post #3

A friend of mine has experienced Never Event #8 (Surgery performed on the wrong body part), went in for work on a tendon in her right ankle, woke up with a cast on the left leg. edit: scrolled further and saw that in the UK we have a different list, so I guess this would count as "Wrong site surgery"

I believe it’s common in the US for the intended (and/or unintended) surgical site to be physically marked in ink before the surgery to prevent left-right mistakes.

I do remember reading about a case where they have marked the wrong place on the head where to drill a hole because they had the wrong patient.

Re: Never Event

#13

Post by cdkmoose »

whatshisface wrote: post #11
dooglius wrote: post #5

Earlier quoted context omitted.

Agreed, the no-suicide one is the worst. What process would you even take other than asking "have you had suicidal thoughts?"

It said "while being cared for in a healthcare facility." You can watch people and not leave dangerous objects around the room.

Depends n your definition of dangerous objects. For example, sheets?

Re: Never Event

#14

Post by AmericanChopper »

rob74 wrote: post #8

Sounds a bit odd to use "never event" for things that can and do happen - but actually I like the term, because it at least expresses the desire to reduce these events as much as possible. Same as https://en.wikipedia.org/wiki/Vision_Zero for traffic deaths.

I think policies like vision zero are a complete governance anti-pattern. When you commit to a goal that is very literally impossible, it can be used as a justification for just about any action that would move the needle closer to the never-achievable target, no matter how insane that action might be.

It is the complete opposite of sensible risk management, and serves only the politicians who find it difficult to publicly admit the fact that some level of risk must be accepted, which isn’t something I think the public should encourage.

It also removes any level of accountability for actually having to achieve a goal, because no achievable goal was ever defined to begin with.

Re: Never Event

#15

Post by Smaug123 »

wrs wrote: post #10
benjijay wrote: post #3

A friend of mine has experienced Never Event #8 (Surgery performed on the wrong body part), went in for work on a tendon in her right ankle, woke up with a cast on the left leg. edit: scrolled further and saw that in the UK we have a different list, so I guess this would count as "Wrong site surgery"

I believe it’s common in the US for the intended (and/or unintended) surgical site to be physically marked in ink before the surgery to prevent left-right mistakes.

Also in the UK. E.g. a big arrow pointing in the general direction of the site, and a dotted circle around the site itself. The low-tech ways are the best!

Re: Never Event

#16

Post by rob74 »

AmericanChopper wrote: post #14
rob74 wrote: post #8

Sounds a bit odd to use "never event" for things that can and do happen - but actually I like the term, because it at least expresses the desire to reduce these events as much as possible. Same as https://en.wikipedia.org/wiki/Vision_Zero for traffic deaths.

I think policies like vision zero are a complete governance anti-pattern. When you commit to a goal that is very literally impossible, it can be used as a justification for just about any action that would move the needle closer to the never-achievable target, no matter how insane that action might be. It is the complete opposite of sensible risk management, and serves only the politicians who find it difficult to pu…

If you asked somebody in the sixties whether it would be possible to have no airplane crashes, they would have laughed at you. And yet, the last crash of a commercial flight in the US is now 14 years ago.

Of course, if everyone agrees that a goal isn't achievable (or it's not worth the effort to achieve it), then it will never be achieved...

Re: Never Event

#17

Post by Amorymeltzer »

lqet wrote: post #6

> Infant discharged to the wrong person When our daughter was born, we didn't let her out of our sight until my wife left the hospital. Sure, they have these bracelets that prevent switching babies (which happened to my wife's grandmother in 1960ies Switzerland), but our worst nightmare was that someone simply took and walked out with her.

Our children each had multiple bracelets, and when one bracelet had to be moved, it was a process involving multiple individuals and had clearly been rehearsed. Each kiddo also had a "baby LoJack" that went off and locked down the entire place if they were moved past a certain line near all doors; we accidentally set it off once and the reaction was immediate.

Sometimes it felt like it was overdone, and sometimes it felt like the most important thing in the world.

Re: Never Event

#18

Post by AmericanChopper »

rob74 wrote: post #16
AmericanChopper wrote: post #14

Earlier quoted context omitted.

I think policies like vision zero are a complete governance anti-pattern. When you commit to a goal that is very literally impossible, it can be used as a justification for just about any action that would move the needle closer to the never-achievable target, no matter how insane that action might be. It is the complete opposite of sensible risk management, and serves only the politicians who find it difficult to pu…

If you asked somebody in the sixties whether it would be possible to have no airplane crashes, they would have laughed at you. And yet, the last crash of a commercial flight in the US is now 14 years ago. Of course, if everyone agrees that a goal isn't achievable (or it's not worth the effort to achieve it), then it will never be achieved...

This proves the exact opposite of what you think it proves. Planes crash all the time. Commercial planes also crash all the time if you want to be extra specific.

Re: Never Event

#19

Post by abenga »

AmericanChopper wrote: post #18
rob74 wrote: post #16

Earlier quoted context omitted.

If you asked somebody in the sixties whether it would be possible to have no airplane crashes, they would have laughed at you. And yet, the last crash of a commercial flight in the US is now 14 years ago. Of course, if everyone agrees that a goal isn't achievable (or it's not worth the effort to achieve it), then it will never be achieved...

This proves the exact opposite of what you think it proves. Planes crash all the time. Commercial planes also crash all the time if you want to be extra specific.

Commercial Airline flights definitely don't crash "all the time."

Re: Never Event

#20

Post by singleshot_ »

abenga wrote: post #19
AmericanChopper wrote: post #18

Earlier quoted context omitted.

This proves the exact opposite of what you think it proves. Planes crash all the time. Commercial planes also crash all the time if you want to be extra specific.

Commercial Airline flights definitely don't crash "all the time."

Gonna need you guys to read CFR 61 and 141 real quick or this discussion is going to languish. More or less: scheduled commercial airline service like American Airlines 587 which crashed into NYC shortly after 9/11 falls under part 141 and crashes are extremely rare.

However, certain commercial operations like air taxis and flight instruction fall under the much less restrictive part 61 and there are tons of incidents all the time.

Original poster meant to say part 141 has been very good at making airline safely profoundly good lately.

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