Purpose

1. “Never events” are the kinds of mistakes that should never happen in medicine, like operating on the
wrong body part or sewing someone up with a sponge still inside. According to a Johns Hopkins
University School of Medicine study, surgeons make such mistakes more than 4,000 times a year in the
United States.
 It is challenging to uncover a consistent cause of errors and, even if found,
to provide a consistent viable solution that minimizes the chances of a
recurrent event. By recognizing untoward events occur, learning from
them, and working toward preventing them, patient safety can be
improved.

Goals
减少因为医生失误而造成的死亡。

2. Try not to get sick. A Wall Street Journal report states that "never events" happen with shocking
frequency. “Never events” are the kinds of mistakes that should never happen in medicine, like operating
on the wrong body part or sewing someone up with a sponge still inside. According to a Johns Hopkins
University School of Medicine study, surgeons make such mistakes more than 4,000 times a year in the
United States. Your boss has asked you, the Marketing Director for a major teaching hospital, to conduct
a study of these mistakes and recommend a list of preventative measures for your hospital. Once
approved, your recommendations will be published in promotional materials for patients and their
families . What are the major reasons these mistakes occur? What are the most common mistakes? Do
these mistakes occur more frequently with certain types of operations or in certain situations? Develop
additional questions, if you feel they are necessary, and write your report.

Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Prevention. [Updated 2020 Oct
17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020
Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499956/