What is a Hospital Never Event?

Some mistakes should not happen in any circumstance in the medical field. In 2001, the former CEO of the National Quality Forum, Ken Kizer, MD, termed the name “Never Events” for these tragic errors that occur in the health care setting.

A list of these events was created, with the basic requirements being that the event was preventable, measurable and had serious implications for the patient. These tragedies should never happen but yet they happen thousands of times per year, resulting in serious injuries and even death.

Types Of ‘Never Events’ Regularly Occurring In Hospitals

The hope by the medical community was that by focusing on these categorized medical errors and mistakes that they would cease to happen and become rare in occurrence.

Unfortunately, even with the attention that these events have received, it is estimated that they still occur at a rate of nearly 80 times per week in the U.S. The National Quality Forum started with 27 events in 2002 and as of 2011 officially recognizes 29 total events, broke down into six categories.

Errors Made By Surgeons

Surgical mistakes have become fodder for urban legend yet they still continue to happen. There are six specific events that are listed in this category.

• Wrong body part. Surgeries that are performed on the wrong area of the body can have life-altering results. Amputations of the wrong limb or removal of the wrong organ are examples of these preventable surgeries.
• Wrong person. Mistakes in preparation and paperwork can result in patients being given the wrong surgery that was intended for someone else.
• Wrong surgery. A mistake in inputting what procedure the patient needs can result in the wrong surgery all together being performed on a patient.
• Foreign objects. One of the most common errors is when a foreign object such as a medical device is left inside the patient. This can cause severe reactions and infections for the patient.
• Anesthesia death. Class 1 or healthy patients that die during or immediately after surgery from anesthesia is considered preventable and an event that should never occur.

There are products or devices that when used improperly can cause patient harm or death. These may be drugs, medical devices or even just blatant misuse of common equipment such as syringes.

• Contamination. Drugs or devices that are contaminated within the medical care setting. These can result in severe infections and other health care issues.
• Improper use of devices. When devices are used in ways not intended, they can cause serious harm.
• Air embolism. When air is allowed to enter the blood stream during a medical procedure, it can cause severe reactions, such as strokes or myocardial infarction.

Hospital Staff Failing To Protect Patients

Hospitals have a duty to ensure the safety of their patients. When harm occurs due to lack of protection, these are also considered “never events”. Three specific situations are identified: Releasing a patient who is unable to make decisions to anyone but to authorized persons, elopement or disappearance of a patient resulting in harm and suicide or attempted suicide while under the care of a medical facility.

Failing to Oversee Patients During A Hospital Stay

Medical practitioners are expected to use extreme caution and care on all patients. Simple mistakes and errors can result in irreversible harm and even death. Some areas of care management that are considered never events are:

• Medication errors
• Incompatible blood products
• Pregnancy issues: death or injury of mother or child during a routine, low-risk labor or artificial insemination with wrong donor egg or sperm
• Hospital falls
• Pressure ulcers. Stage 3 or 4 acquired after admission
• Loss of irretrievable biological specimen
• Lack of follow up on tests, resulting in harm

Environmental, Radiological & Criminal

If you or a loved one has been injured or fatally harmed in a medical error that is considered a “never event”, you need an experienced Chicago medical negligence attorney to represent you in your case. Our team at Rosenfeld Injury Lawyers LLC has attorneys and medical experts that will fight for your right for financial compensation. We offer a free consultation to discuss your case and there is never a fee unless we are able to obtain a monetary award for your injuries.

Never event resources:

• http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2012/Jun;9%282%29/Pages/58.aspx
• http://www.psnet.ahrq.gov/primer.aspx?primerID=3
• http://www.amednews.com/article/20130121/profession/130129976/2/
• http://en.wikipedia.org/wiki/Never_events