Four to nine factors contributed to each 'never event,' study finds

ROCHESTER, Minn. — Why are major surgical errors called "never events?" Because they shouldn't happen — but do. Mayo Clinic researchers identified 69 never events among 1.5 million invasive procedures performed over five years and detailed why each occurred. Using a system created to investigate military plane crashes, they coded the human behaviors involved to identify any environmental, organizational, job and individual characteristics that led to the never events. Their discovery: 628 human factors contributed to the errors overall, roughly four to nine per event. The study results are published in the journal Surgery. Read more... (http://www.insightnews.com/health/13729-four-to-nine-factors-contributed-to-each-never-event-study-finds)

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