“Never Events” Are Always Happening
What Are Never Events?
So-called never events are medical mistakes so egregious that they are never supposed to happen. Since never events are not natural complications of medical procedures, they are, by definition, avoidable. As such, never events are almost always grounds for a medical malpractice lawsuit.
Here’s an example. A 67-year-old patient was admitted to Cape Fear Valley Medical Center in Fayetteville, North Carolina, with minor injuries from a fall. A brace was put on his leg, which soon developed fist-sized bedsores and became severely infected. One infection was so dangerous that the man’s leg had to be amputated in an attempt to save his life. Sadly, he died shortly after his family managed to have him transferred to another hospital.
At Leventhal & Puga, P.C., we have seen countless clients and their loves ones who were injured by falls and bedsores while being treated in a healthcare facility. Since these injuries are wholly preventable, they indeed count as never events; we can certainly attest they are the most common ones.
According to the National Quality Forum, there are 29 defined never events (sometimes called “sentinel events” or “serious reportable events”). They are:
- Surgical events.
- Surgery or invasive procedure performed on the wrong site.
- Surgery or invasive procedure performed on the wrong patient.
- Wrong procedure performed on a patient.
- Object unintentially “left behind” inside a patient after a procedure.
- Death of a healthy, non-smoking patient during or after a procedure.
- Product or device events.
- Death or serious injury to a patient due to contaminated drugs, devices, or biologics provided by healthcare facility.
- Death or serious injury to a patient due to a device used or functioning other than as intended.
- Death or serious injury to a patient by intravascular air embolism.
- Patient protection events.
- Discharging a patient who is unable to make decisions to the care of anyone other than an authorized person.
- Death or injury due to patient disappearance (elopement).
- Suicide, attempted suicide, or self-harm of a patient who is admitted to the facility.
- Care management events.
- Death or serious injury to a patient due to a medication error (wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, wrong administration).
- Death or serious injury to a patient due to unsafe administration of blood products.
- Death or serious injury to a mother during labor and delivery in a healthcare setting if the pregnancy was low-risk.
- Death or serious injury of a newborn caused during labor and delivery (birth injury) in a low-risk pregnancy.
- Death or serious injury to a patient due to a fall in a healthcare setting.
- Stage 3, 4, or unstageable pressure ulcers (bedsores) a patient acquires after being admitted to a healthcare setting.
- Artificial insemination with the wrong donor sperm or egg.
- Death or serious injury to a patient due to the loss of an irreplaceable biological specimen.
- Death or serious injury to a patient due to healthcare staff’s failure to follow up or communicate laboratory, pathology, or radiology test results.
- Environmental events.
- Death or serious injury to a patient or staff member due to electrocution during patient care process in a healthcare setting.
- Any incident where systems designed to deliver oxygen/another gas to a patient contain no gas, the wrong gas, or contaminated gas.
- Death or serious injury to a patient or staff member due to burns during patient care process in a healthcare setting.
- Death or serious injury to a patient due to healthcare providers’ use of physical restraints or bedrails.
- Radiological events.
- Death or serious injury to a person from a metallic object coming into contact with an MRI unit.
- Criminal events.
- Any care ordered or provided by someone impersonating a licensed healthcare provider.
- Abduction of a patient.
- Sexual abuse/assault of a patient or staff member in a healthcare facility.
- Death or serious injury to a patient or staff member due to assault in a healthcare facility
Never events are especially deadly. Of the never events that were reported to The Joint Commission between 2007-2017, 71% were fatal to the patient.
How Common Are Never Events?
No one knows for certain! There is no nationwide reporting enforcement or auditing for licensed healthcare centers. At the state level, only half of U.S. states have a system set up wherein hospitals are supposed to report select events to them, and rarely require all 29 recommended by the NQF.
One 2013 study estimated around 4,000 surgical never events every year in the U.S., but the numbers on the ground add up very differently.
Dr. Marty Makary, in his book Unacceptable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, cites an example of a never event from his medical training. One of his fellow residents left a one-foot-long, two-inch-wide metal bar inside a patient’s abdomen after closing up his surgery. The patient was “quietly” taken back to the operating room to remove it, but at the time, the incident was not reported to any higher authority.
Makary said that some reputable hospitals he visited around the time the book was written in 2012 told him that sponges are left inside patients three or four times a year per hospital. There are to date 5,534 registered hospitals in the United States, and that is only one type of never event. If this estimate holds true, a staggering number of patients leave surgery with a sponge inside them. Makary summed up later on in the book, “These catastrophes should simply never occur. Never events sound shocking, but most every hospital in the country, including every hospital I have ever worked in, has had at least a couple every year.” That’s a far cry from what has been—and is being—reported.
Are Never Events Reported to a Higher Authority?
Every state sets its own requirements for reporting never events—if it sets any at all. To date, around 25 states do have mandatory reporting of never events, but few require the at-fault hospitals to release the data publicly. Even if they did, most people would not know what to look for—and that’s how hospitals like it.
In Colorado, never events are tracked through a system called “occurrence reporting.” Healthcare facilities, including long-term care centers such as nursing homes, must report any qualifying event within 24 hours to the Health Facilities and Emergency Medical Services Division under the Colorado Department of Public Health and Environment. These 14 events include:
- Unexplained deaths
- Brain injuries
- Spinal cord injuries
- Life-threatening complications of anesthesia
- Life-threatening transfusion errors/reactions
- Severe burns
- Missing persons
- Physical abuse
- Verbal abuse
- Sexual abuse
- Misappropriation of property
- Diverted drugs
- Malfunction/misuse of equipment
Will Colorado disclose these events to the public—specifically, which hospital has seen the most never events? Of course not. Colorado Revised Statutes §25-1-124 states, “The information in such reports shall not be made public upon subpoena, search warrant, discovery proceedings or otherwise.” However, general data is available that tabulates how many of each kind of reportable event happened that year.
Checklists and Honesty Could Stop Most Never Events
Bestselling author Dr. Atul Gawande promotes a “groundbreaking” method to prevent most never events and medical mistakes—a checklist. Together with Dr. Marty Makary, he developed a simple surgical checklist for the World Health Organization, which is now standard procedure in many countries (not including the United States, somehow). Checklists like this could save lives; and letting patients see which hospitals are making these preventable medical errors could save even more.
As Makary concludes in Unaccountable, “Public reporting would enable patients to see which hospitals rarely have a never event and which have them often. The public is right to be concerned by this persistent problem in medicine. Public scrutiny of hospital never event rates would no longer simply mean a quiet monetary settlement with a patient—it would mean a costly PR nightmare.”
“In the past century, medicine learned to use an incredibly powerful tool that has saved lives and improved the efficacy of treatments and the quality of care. That tool was data.
“Yet even as our system relies on evidence to function, we fail to make the same tool available to patients who are confronting decisions of critical, even life-and-death importance….Now, we need a transparency revolution.”
We at Leventhal & Puga, P.C., couldn’t agree more. If you suffered a serious, avoidable medical mistake, we may be able to help. Having an experienced and knowledgeable Colorado medical malpractice attorney on your side to sift through the evidence and deal with the hospital will help you focus on healing and take the burden from your shoulders. For a no-cost consultation about your case, please call us at (877) 433-3906. We take cases across the Nation.