Never Events Will Never Go Away

In 2002, the National Quality Forum, a non-profit that aims to improve health care, established a list of serious reportable events which have become known as never events.  Currently it lists 28 such events.  Never events are medical errors that are so serious they should never occur.  Medicare eventually adopted its own similar list of never events, and will not pay for care associated with those events.  Unfortunately, some of those events cannot be avoided, even with the best care.  Nonetheless, Medicare hoped its policy would speed up the identification and correction of those flawed processes which end up causing serious medical complications and death.  A comparison of the National Quality Forum and Medicare never events can be found at this link. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2814808/figure/F1/

Never events are almost always a consequence of human error (medical malpractice), often the result of poor training or poor procedure, as an article in the San Diego Union-Tribune recently reported.  You can read the story here.  http://www.utsandiego.com/news/2013/aug/16/tp-sharp-fined-75k-for-surgical-error/  In that case, a physician almost removed a man’s only healthy testicle after initiating surgery to remove a diseased testicle on the wrong side – a clear never event.  An investigation revealed the surgical team did not follow the procedures designed to avoid a wrong-sided surgery.  Following the event and additional training, random audits revealed 100% compliance with hospital surgical policies.

The article also noted that this was the second time a hospital was fined in California for a wrong-site surgery in less than a year.  When you consider that there are 28 different  never events and 50 states, it is easy to see how pervasive such events are in the U.S.          A recently study published in the journal Surgery estimates that wrong-site surgery alone occurs 20 times each week.  While such events almost always spark change, complacency often erodes vigilance and good procedure can be affected over time.  After all, we are only human.

There is only so much patients can do to protect against never events.  Making sure potential surgical sites are appropriately marked before going under anesthesia at least is one of them.

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