A medical doctor and former CEO of the National Quality Forum coined the term “Never Event” in 2001, to describe medical errors that are particularly shocking in nature. Particularly shocking errors include surgery at the wrong site, food meant for stomach tubes going into test tubes, air bubbles going into IV catheters or, in short, any incident that should never have occurred. New York Never Events require extreme neglect to happen, hence the reason they are so rare.
According to the U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Patient Safety Network, the term has since expanded to include a number of adverse events that have a clear and identifiable cause and that healthcare professionals could have prevented via standard methods and means. These events, sadly, often result in substantial disability or death. Since the development of the initial Never Events list in 2002, medical professionals have revised it multiple times to include 29 severe reportable incidences. The healthcare industry groups these events into seven categories: patient protection events; product or device events; care management events; surgical or procedural events; radiological events; environmental events; and criminal events.
Fortunately, Never Events are rare. For instance, one study discovered that the average hospital will only see a claim for surgery at the wrong site once every five to 10 years. Unfortunately, when these adverse incidences do happen, they are often fatal. Of the Never Event claims the Joint Commission received in the recent decade, 71 percent resulted in fatality.
Though Never Events are uncommon, the commission now requires that hospitals and other healthcare centers report sentinel events, which are unexpected events that result in serious injury or death. When sentinel events occur, the commission orders an investigation to determine the root cause of the event. Though it does not require hospitals to divulge the mistake, it recommends that they do so and that they apologize to patients, report the incident and relinquish all fees related to the event.
The information in this post is not legal advice. It is for educational purposes only.