Never Events in Hospitals

Far too many patients are go into a hospital hoping to get better only to find themselves at the end of a medical error causing them even more harm.

Reports indicate hospital-acquired health care problem may result in as many as 187,000 deaths in hospitals each year as well as 6.1 million injuries each year. One 2011 report found that one out of three hospitalized patients was harmed during treatment.

Further, the cost of these errors is also large, with estimates ranging from $393 billion to $958 billion. Thus, the cost could amount to more than 30% of American health care spending.

What are “Never Events”?

Adverse Events Not Necessarily “Never Events”

Adverse events include such things as patient procedural errors, medication errors, and hospital-acquired infections among others common occurrences. These in particular are so widespread that they have come to be viewed almost as a necessary risk of medical care.

They are so common now that in many cases, it is argued by the medical providers who make these mistakes that they do not even rise to the level of medical negligence necessary for a medical malpractice claim.

Never Events Should Never Occur

“Never Events” stand out even from these adverse events. “Never events” are serious patient safety incidents that should never occur in a health care setting because they can be eliminated, or at least sharply reduced, with readily available preventative measures. The term “Never Event” was coined in 2001 by Dr. Ken Kizer of National Quality Forum.

One classic and all too common example of a never event is wrong-site surgery, where, for example, a healthy right leg is amputated instead of a diseased left leg. Worse yet, organ are removed or other surgical procedures are conducted on the wrong patient. With proper precautions in place, and use of multiple fail-safe measures, such as checklists, surgery should never be done on the wrong-site or on the wrong person.

Never events are shocking because they are adverse events that (1) are unambiguous, so they can be clearly identified and measured; (2) result in serious injury such as death or significant permanent injury or disability; and (3) are usually preventable. Never Events are also called “Serious Reportable Events,” because hospitals are required to report these incidents.

What is Being Done to Reduce Never Events?

The federal government, hospitals, and medical practitioners are using many tools to reduce never events. For Medicare and Medicaid patients, the federal government now denies reimbursement for certain never events and for hospital readmissions related to those errors. Hospitals are on notice that they can no longer pass the cost of treating these hospital errors on to the federal government. Instead, the hospitals will foot the bill for caring for these preventable errors. The hope is that financial incentives will encourage hospitals to take action to reduce the problem. There is also an important principle: hospitals should not profit from these errors.

Specific Never Events Targeted for Elimination

Specific never events have been targeted for elimination. For example, under the new health care law, the Centers for Medicare and Medicaid Services has instituted a private-public “Partnership for Patients,” which now includes more than 3,700 hospitals. With the goal of decreasing hospital-acquired health problems by 40% by the end of this year (2013) compared with 2010, the Partnership has focused its attention on nine specific hospital-acquired conditions:

• Adverse Drug Events
• Catheter-Associated Urinary Tract Infection (CAUTI)
• Central Line-Associated Blood Stream Infections (CLABSI)
• Injuries and Falls from Immobility
• Certain Obstetrical Adverse Events
• Pressure Ulcers
• Surgical Site Infections
• Venous Thromboembolism (VTE)
• Ventilator Associated Pneumonia (VAP)

The programs should translate to compensation for patients for the damages caused by medical negligence resulting in “never events.” After all, it will be more difficult for medical providers to argue that these common errors were not preventable. And if they are reasonably preventable, then the failure to prevent them is not only unacceptable medical negligence, it is morally reprehensible.

Do Not Delay! Medical Malpractice Cases Have Unique Deadlines

If you or a loved one has been negatively affected by a hospital-acquired health care problem, particularly one of the never events, contact an attorney as soon as possible. There are unique and strict deadlines associated with medical malpractice claims.