Never Events: Thousands Per Year

 Never Events happen thousands of times per year nationally.  In NY, my state, 123 happened in 2024 with patient harm.  When a never event happens, not only are patients injured, the physician's career and reputation are destroyed. 

Never events are system errors, not individual ones yet individuals ultimately absorb the full damages that these occurrences cause.  They need to be prevented at all costs.  That is why I developed my tool:

                                                                SurgeonVerify.  

Check it out here.

Universal Surgical Safety Checklist and Timeout

Pre-Procedure Verification & Documentation

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Procedure Information

Procedure Name:

Procedure Date:

Time In (Timeout Started):

1. Patient Identification Verification

Has the patient stated their own name verbally to you?

Has the patient stated their birth date to you in their own voice?

Have you read the patient's name off the EMR and asked the patient to verify that is their name?

Have you read the patient's birth date off the EMR and asked the patient to verify?

2. Procedure Understanding & Consent

Have you asked the patient to state the procedure that they're having in their own words?

Have you asked the patient to state in their own words why they're having the procedure?

Has the patient had the opportunity to ask any questions regarding the indications for the procedure?

Have you discussed the most common and most serious risks and side effects of the procedure with the patient?

Has the patient been given a chance to ask any questions regarding these risks that you just discussed?

Have you verified independently the patient's name, date of birth, date of the procedure, name of the procedure, and that the risks and benefits were discussed?

3. Laterality (if applicable)

Is there a laterality for this procedure?

Which side?

4. Imaging Review

Is imaging available in the room?

Have you checked the imaging?

5. Pre-Procedural Testing

Pre-procedural testing ordered/done?

Reason not indicated:

6. Equipment & Sterile Field

Is all necessary equipment for this procedure in the room and available?

Has all equipment been checked and verified?

Is the sterile field established?

7. Antibiotic Prophylaxis

Does the patient need perioperative antibiotics?

If no, indicate why:

8. Timeout Completion & Signatures

Time Out (Timeout Completed):

Performing Physician Name:

Witness/Staff Name:

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Career Change Decision Tool

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Question 1: Are you thinking of changing to a new job?

Question 2: Rate your current job satisfaction

(1 = least satisfied, 10 = most satisfied)

5

Question 3: Rate your satisfaction with your salary

(1 = least satisfied, 10 = most satisfied)

5

Question 4: Rate your satisfaction with your team at work

(1 = least satisfied, 10 = most satisfied)

5

Question 5: Rate your satisfaction with your commute

(1 = least satisfied, 10 = most satisfied)

5

Question 6: Rate your satisfaction with your work-life balance

(1 = least satisfied, 10 = most satisfied)

5

Question 7: Rate your relationship with your direct report/leadership team

(1 = worst, 10 = best)

5

Question 8: Rate your sense of appreciation or feeling appreciated at work

(1 = least appreciated, 10 = most appreciated)

5

Question 9: Rate your sense of intellectual stimulation/fun at work

(1 = least, 10 = most)

5

Question 10: Rate your sense of personal identity tied to your current workplace

(1 = least, 10 = most)

5

Question 11: Rate your tolerance for change

Question 12: Would you experience regret regarding a missed opportunity?

Your Result

0

Scale: ≤-750 (Strong STAY) | -750 to +750 (Inconclusive) | ≥+750 (Strong GO)

Your result is inconclusive

Would you like to answer additional questions for more clarity?

Additional Questions

Additional Question 1: Is promotion at your current job important to you?

Additional Question 2: Would leaving realistically and likely negatively impact your financial security?

Additional Question 3: If the new job didn't work out, would future employment be difficult to attain?

Additional Question 4: If you take the new job and it doesn't work out, would you experience significant regret/self-doubt psychologically?

Additional Question 5: If you remain in your current job and experience burnout, will you have severe regret for not having gone after the new job?

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