Surgical “never events”— or occurrences that should never happen, such as operations on the wrong part of the body, or foreign objects left in the body after surgery — are happening at least 4,000 times per year, study results indicate.

The study, conducted by Martin Makary, MD, MPH, and colleagues at Johns Hopkins University in Baltimore, revealed some startling results. The investigators estimate that surgeons in the United States leave a foreign object (for example, a sponge or towel) inside a patient’s body after an operation 39 times a week, perform the wrong procedure on a patient 20 times a week, and operate on the wrong part of the body 20 times a week.

The researchers analyzed records in the National Practitioner Data Bank (NPDB), a national repository of medical malpractice claims, including 9,744 paid malpractice judgments and claims from 1990 to 2010. During the study period, they estimated a total of 80,000 never events took place, accounting for 4,044 events in the United States each year.

By law, hospitals are required to report to the NPDB all never events that lead to a settlement or judgment, but the researchers believe that these numbers may appear lower than they really are because not all items left behind in surgery are discovered.


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A total of 9,744 malpractice judgments and paid claims were identified during the 20-year study period relating to such events, with payments totaling $1.3 billion. Mortality resulting from never events occurred in 6.6% of patients, permanent injury occurred in 39.2%, and temporary injury in 59.2% of patients.

Many medical centers have implemented patient safety procedures, such as counting sponges and towels before and after surgery, marking the surgery site with indelible ink before the procedure, and making sure that surgery plans and medical records match the patient, but these efforts are not foolproof, the researchers noted. Some hospitals are moving towards electronic bar codes on materials and instruments to prevent error.

“There are mistakes in healthcare that are not preventable,” Makary said in a press release. “Infection rates will likely never get down to zero even if everyone does everything right, for example. But the events we’ve estimated are totally preventable. This study highlights that we are nowhere near where we should be and there’s a lot of work to be done.”