Posted by Bill Sandweg on 12 March 2018.
The term “Never Event” was created in the early 2000’s to denote an event that should never occur in the presence of good medical care. It is now used to describe events which are clear, which cause serious injury or death, and which are usually preventable. There are now 29 listed never events. Every one constitutes what any reasonable person would call medical malpractice.
This is a picture of a never event.
Some surgeon left a hemostat inside a patient. This will not happen if everyone is doing their job. Other examples of never events are wrong site surgery, wrong patient surgery, wrong surgery, administration of contaminated drugs, development of an air embolism, patient suicide, death of a mother following childbirth in a low risk pregnancy, death or serious injury after patient disappearance, development of Stage 4 pressure ulcers, death or serious injury due to electric shock, and death or serious injury due to a burn. If you have been counting, you know there are still more never events but you get the idea.
I wish I could tell you that never events never happen or even that they happen infrequently. Neither statement is true, however. In 2013, a study concluded that there were 4,000 surgical never events alone in the United States. A study by physicians at Johns Hopkins Medicine in Baltimore found that major lapses in patient safety were responsible for more than 200,000 patient deaths, more than 2.4 billion extra days in the hospital and between $17 and $29 billion in extra medical spending in the United States each year. The authors did not limit their definition of “major lapse” to only never events but there is a strong correlation.
More than 25 states require that never events be reported to them but only a few make the reports public. This is just another example of the secrecy with which the medical profession surrounds its mistakes. Consumers and prospective patients deserve to know who provides bad care and who does not. There is also no requirement in most places that the patient ever be told that he or she was the victim of a never event. In fact, my experience has been that patients are often misled about what happened to them. They are led to believe that no one was at fault for their injury. They are led to believe it was just one of those things that could not be avoided.
Many who are advocates for quality in medical care have urged sharing of information about never events in an attempt to reduce or eliminate them. Only by sharing information about mistakes can health care providers learn from each other’s experience. For its part, The Centers for Medicare and Medicaid Services refuses to pay for medical care resulting from a never event. The hope is that health care providers will act to preserve their income stream by improving the quality of care and preventing never events. This approach has not eliminated never events, but it is a step in the right direction.
Other advocates for health care reform have called for the creation of “always events.” These are safety measures designed to improve patient outcomes and reduce the occurrence of accidents. They range from improved communication procedures to the use of checklists. These advocates also urge that there be transparency when a patient is injured by medical error.
Be an informed consumer of medical services. There is some information out there and before you choose a doctor or go to a hospital, you should review what information is available. You can’t guarantee a good outcome but you can improve your chances.