The Never Event.

In 2001, the concept of “never events” was introduced.  The idea was that a never event was one which was identifiable, caused serious injury or death and was almost always preventable.  The original list has grown and there are now 29 recognized never events.

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Never events are grouped into seven categories.

  • Surgical or procedural events
  • Product or device events
  • Patient protection events
  • Care management events
  • Environmental events
  • Radiologic events
  • Criminal events

Examples of surgical events are operations on the wrong patient, on the wrong body part, right patient but wrong surgery or leaving a surgical instrument or foreign object behind in the patient’s body.

Product or device events might arise from an air embolism, a product being used in an inappropriate manner or death or serious injury due to contaminated drugs or products.

Patient protection events include discharging a compromised patient to an unauthorized person, patient disappearance and patient suicide.

Care management events are a big category.  Examples of care management events are medication errors (wrong patient, wrong dose, wrong medication, etc.), maternal death in a low risk delivery, death of a neonate in the hospital after a low risk delivery, unsafe administration of blood products, death or serious injury due to failure to communicate test results, and, significantly, serious pressure ulcers which develop after admission to a health care facility.

Environmental events include electric shocks, mistakes involving the delivery of oxygen, burns and death or serious injury resulting from bed rails or patient restraints.

Radiologic events involve any injury arising out of the presence of metal in an MRI area.

Criminal events speak for themselves.  Examples are patient assaults, patient abduction, injury due to a person impersonating a physician or other health care provider and sexual abuse of a patient.

A never event may be a rare occurrence at a particular hospital or care facility but, when they occur, they usually cause great harm to the patient.  According to recent reports, almost three out of four never events result in death.  While never events may be rare at a given facility, there are so many facilities in the United States that never events occur frequently.  According to some reports, as many as 4,000 surgical never events occur each year.

There has been a lot of pressure on hospitals and other care facilities to eliminate never events.  For example, Medicare and now many health insurers are refusing to pay bills for treatment associated with a never event.  Some states are requiring reporting of all never events and are making those reports public to encourage facilities to do a better job.

So far, nothing has worked and never events continue to occur.  If you or a loved one become the victim of a never event, you need to seek prompt legal assistance to protect your rights.



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