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What is a Never Event?
A never event is a mistake without an excuse. According to the Agency for Healthcare and Research Quality, there are 29 errors defined as “never events.” They are grouped into different categories. They include:
- Care management – An error in administering medication or blood products administered in an unsafe manner that leads to serious injury or death. Care management events can include:
- Harm to a mother or baby during labor or delivery in a low-risk pregnancy
- Artificial insemination with the incorrect sperm or donor egg
- The loss of a biological specimen or harm to a patient as a result of failing to provide follow-up care.
- If a patient acquires stage 3 or 4 pressure ulcers (bed sores)
- If a patient falls when in a healthcare setting.
- Product/device – When a
- medical device is used in an incorrect manner or when a medical device is misused or a tainted medical device or drug is used and causes death.
- Patient protection – When a care facility releases a patient who cannot care for himself to someone other than an authorized person,
the disappearance of a patient that leads to disability or death or, the suicide or attempted suicide of a patient that occurs while the patient is being cared for in a healthcare facility.
- Environmental – examples include: electrical shock, oxygen lines containing no gas or the incorrect gas, burn injuries, and the use of bed restraints that cause serious injury or death.
- Radiological events – When a negligent person allows for the introduction of a metallic object during an MRI, causing death or serious bodily injury.
- Surgical error – For example, when surgery is performed on an incorrect body part or the incorrect patient, the incorrect surgery is performed, or a foreign object such as a surgical sponge or medical device is left inside of a patient’s body.
- Criminal events – Care provided by someone impersonating a health doctor, abduction of a patient, sexual abuse of a patient by a health doctor or physical assault of a patient in a healthcare setting.
These things should not ever occur in a healthcare setting and when they do, the doctor or healthcare facility can be held legally liable for the consequences.
Never Event Attorney
Doctors make mistakes. While some errors may be understandable, there are certain errors that no doctor should ever make.
These events have been referred to as “never” events. Recent studies show that a never event may occur as many as 80 times each week.
How Often Do Never Events Occur?
A recent study, based on data collected between 1990 and 2010, indicates around 80,000 never events have occurred in the U.S. during that time.
According to the study:
- Patients underwent the incorrect procedure 20 times a week.
- The incorrect body part was operated on 20 times a week.
- Surgeons left foreign objects in a patient 49 times a week.
Not surprisingly, surgeons that had a history of malpractice made it more likely that one of these events would occur.
Medical Advances and Imperfections
Having to undergo a medical procedure is never without a certain amount of trepidation; medical procedures are usually linked to health scares, and those are stressful enough. Modern medicine continues to advance its methods and capabilities, and our healthcare system is all the better for it. We are living healthier and more active lives because of modern medical accomplishments.
The medical profession, however, is comprised of medical professionals – people who make mistakes just like everyone else. Some of the mistakes medical professionals make are more understandable than others, and some should simply never happen under any circumstances.
The term never event was first used by the National Quality Forum (NQF) in 2001 to refer to medical errors of such shocking nature that they simply should have never happened. There is no possibility for a reasonable or understandable explanation. The term has been expanded over the years to encompass adverse medical events that share common traits:
- They are unambiguous (able to be clearly identified and measured).
- They are serious, resulting in significant disability or death.
- They are usually preventable
Never Events and Sentinel Events
Although true never-events are relatively uncommon, they are so devastating in effect that they must be treated with the utmost seriousness. Often never events are found to be indicative of a fundamental safety issue within the medical organization where they’ve occurred.
Since 1995, in fact, the Joint Commission – an independent and nationally recognized not-for-profit hospital-accrediting organization – has recommended that hospitals report sentinel events. These events are identified as an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof. The Joint Commission categorizes the NQF’s never events as sentinel events.
Recommendations and Mandates
In the event of a sentinel event, the Joint Commission mandates that a root cause analysis (RCA) of the event be performed to cull out any contributing factors that are systemic to the healthcare facility and to highlight exactly where improvements must be made. The Leapfrog Group, which is a national nonprofit organization that attempts to drive the quality and safety of American health care, goes a step farther by recommending that healthcare organizations employ a checklist of guidelines whenever a never event occurs:
- Sincerely apologize to the affected patient and/or family;
- Report the event to at least one of the pertinent reporting agencies, including the Joint Commission;
- Perform an RCA that is consistent with the chosen reporting company;
- Waive all related costs;
- Make never event policies available to patients and payers (when requested);
- Advise the patient and/or family of the adverse event within 60 minutes of its discovery;
- Have an accessible protocol in place for providing caregiver-support;
- Meet with the patient and/or family (if they are willing) to gather evidence for the RCA, to review the RCA’s conclusions, and to share the plan for future action regarding the prevention of further never events; and
- Perform an annual review to ensure continued adherence to each of these elements for every never event that’s occurred in the healthcare facility.
Only by following an aggressive policy such as the one laid out by Leapfrog, can healthcare institutes learn from their mistakes and curtail them. This includes the public disclosure of never events and the implementation of an ongoing, systematic, self-checking, and thorough plan to eradicate never events.
As a patient, you have the right to be involved at every level of your medical care. Talk to your doctor and medical team; ask questions; voice your concerns; and when feasible, get a second opinion if you’re not comfortable with the responses you receive. Dealing with medical procedures is stressful in the best of times; bringing a friend or family member to act as your advocate can help you get a broader picture of your medical team and of the medical procedure that they’re recommending. There are certain enquiries that should always be made before embarking on an invasive medical procedure:
- Does the team take recommended time outs during procedures to make sure everything is going according to plan;
- Who will oversee the time outs (don’t accept double covering – when a medical professional is responsible for more than one procedure at a time);
- Is there a marking system in place to identify that the surgery site is correct and that the team is indeed working on the right patient?
These are all important questions, and if something seems wrong to you once you’ve gone over these points with your medical team, something may be wrong. Don’t undergo any medical procedure with medical professionals who can’t or won’t adequately address each of these important safety issues. It’s your right to advocate for your own safety. Don’t be intimidated: speak up!