“Never Events” are a specific set of incidents that occur in a medical setting as a result of preventable errors or substandard care.
These specific incidents are named in reference to the fact that they almost by definition the result of medical negligence. Following proper procedures, standards and protocols can eliminate them entirely.
Unfortunately, even though there is widespread acknowledgement that these mistakes should never occur, many investigations have found that these “never events” occur thousands of times each year.
Responding to the challenge of preventing never events, the American Association of Critical-Care Nurses (AACN) has developed “Practice Alerts” that provide evidence-based guidelines designed to sharply reduce specific never events. These Practice Alerts are best practices that should be implemented in the clinical setting to protect patients. The AACN also notes that, by protecting patients, nurses also will be protected from the trauma that may result from being involved in an avoidable medical error.
For example, following proper standards can prevent the never event known as ventilator-associated pneumonia (VAP). VAP refers to a lung infection which develops in a patient who is using a ventilator. This usually occurs when the tube used becomes infected with germs that enter the patient‘s lungs.
Ventilator-associated pneumonia is deadly, resulting in death in 20-40% of cases. For each 1000 ventilator days, there are between 10 and 35 VAP cases. The ACCN Practice Alert for ventilator-associated pneumonia identifies three key steps that critical care nurses should follow to prevent VAP. Each of these are supported by multiple clinical studies in a variety of patient populations and settings:
- Elevate the head of the bed by 30-45 degree. This simple, no-cost technique can make a dramatic difference in gastric reflux as well as VAP. Yet studies and literature show there is poor compliance with this recommendation.
- Use an endotracheal tube so that secretions can be continuously drained.
- Change ventilator circuits routinely based on duration of use.
The ACCN has also issued a Practice Alert for Oral Care in critically ill patients to prevent VAP. The goal is to prevent infections by improving oral care in patients at high risk of VAP by:
- Brushing teeth, gums, and tongue at least twice daily with a soft toothbrush.
- Providing oral moisture to the mouth and lips every two to four hours.
- Using a medical rinse twice daily during hospitalization, from admission to discharge.
It is always critical to have an individual assessment of situations where medical malpractice might have occurred leading to serious injury or wrongful death of a patient. However, when a never event occurs, like ventilator-associated pneumonia, there is a very significant chance that medical negligence was the cause. Failure to follow these clinical guidelines is likely evidence of malpractice.
Due to the many challenges and unique and critical deadlines associated with medical malpractice claims, where there is suspected medical negligence that has caused serious personal injury or wrongful death, it is important to contact an attorney experienced in medical malpractice claims as soon as possible.
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