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Panel Presentation

Care Equity, Quality, and Safety

Near Misses, Never Events, and Just Plain Scary Cases

Sunday, October 18, 2026
8:00 AM - 9:00 AM PT
Location: 406A

    Moderator(s)

  • NJ

    Nausheen Jamal, MD, MBA

    Harry Carothers Wiess Professor & Chair of Otolaryngology-HNS
    University of Texas Medical Branch Dept of Otolaryngolgy
    Galveston, TX, United States

    • Panelist(s)

  • KK

    Kiran Kakarala, MD

    Professor and Vice Chair for Patient Safety and Quality Improvement
    University of Kansas School of Medicine
    Kansas City, KS, United States

  • Soham Roy, MD

    Chair, Department of Pediatric Otolaryngology
    Children's Hospital Colorado
    Aurora, Colorado, United States

  • Matthew M. Smith, MD, MPH

    Associate Professor
    Cincinnati Children's Hospital Medical Center
    Cincinnati, OH, United States

Disclosure(s):
Nausheen Jamal, MD, MBA:

faculty for this accredited education activity has no relationship(s) with ineligible companies to disclose.

Matthew M. Smith, MD, MPH:

faculty for this accredited education activity has no relationship(s) with ineligible companies to disclose.

Near misses, sentinel events and horrific complications affect patients and families often irreversibly. They also increasingly draw scrutiny to surgical practices and systems, surgeon technical competencies, and evidence-based decision-making. In the last decade numerous systems have been gravely impacted by the failure to prevent, recognize, or respond to major surgical errors or complications. In this interactive panel, we present real-life cases that went wrong, how these problems were addressed, and potential solutions to avoid or mitigate these crises in the future. Through these case presentations we emphasize key principles of root cause analysis, health system safety, institutional safety culture, and quality improvement interventions to address these types of events in otolaryngic surgery.

Learning Objectives:

  • Recognize the wide range of unexpected catastrophic adverse events that can occur in otolaryngology-head and neck surgery through actual case discussions and storytelling.
  • Learn specific interventions that may be able to reduce the likelihood or mitigate these never and near miss adverse events.
  • Highlight system and human factors that lead to never events and outline performance improvement strategies to mitigate occurrences.