Never events. Well, hardly ever.

Many thanks to Ishani Ganguli for inviting me to write an op-ed in Virtual Mentor, the journal she guest-edited for the American Medical Association.  In it, I discuss the persistent rate of wrong-site surgeries and argue that financial penalties for such "never events" are ineffective:

In the face of slow progress, there is little doubt why the regulatory hammer is employed. But it is a crude tool. Its effectiveness as a deterrent is minimal because it does not address the structural issues underlying the problem. It emphasizes a particular outcome rather than a process that will achieve it. It penalizes people when it is too late to make a difference. Finally, it serves mainly to create resentment among those who are targets for improvement. Such is often the nature of regulation, no matter how well intended.

I argue, instead, for the power of training in crew resource management and transparency. 

Transparency, combined with a commitment to and training in crew resource management, enables doctors to hold themselves accountable to the standard of care they would wish for their own family members. This combination of ingredients offers far more potential than financial penalties or other regulatory actions for sustained process improvement in the operating rooms of America.

The entire article is here.   I welcome your comments.