Never events are serious errors, oversights, and crimes that occasionally take place in the health care industry and can cause serious injury or death to patients. As the term suggests, these events should never be allowed to occur. As of 2011, seven main categories of never events existed that were broken down into a total of twenty-nine specific events. While rare, never events are the subject of serious investigation and calls for improvement.
Definition of Never Events
Ken Kizer, a physician and former chief executive officer of National Quality Forum (NQF), coined the term never event in 2001. In its first usages, the term referred to serious medical errors that should never be allowed to happen. The NQF, an organization that supports patient rights and protections, conducted studies of such medical errors and reported its findings in the hopes of drawing attention to never events and creating new safeguards against them.
By 2002, the NQF compiled a list of never events. The concept began spreading and gained greater acceptance by the medical community and public. Over time, the concept expanded to include a wider range of harmful events experienced by patients. These events had to fit three criteria; they had to be serious enough to result in a patient's death or disability, clear enough to identify and measure, and potentially avoidable.
Categories and Events
The NQF modified its list of never events in 2011 to include twenty-nine specific events divided into seven main categories. These events cover a wide range of patient experiences and medical personnel actions before, during, and after medical procedures. The categories include surgical events, product or device events, radiologic events, environmental events, patient protection events, care management events, and criminal events.
One of the main categories of never events involves surgical procedures. Surgery is a delicate and complicated task. If performed improperly, it can lead to an array of hazards for patients. Some of these hazardous events include surgeries performed on the wrong patient, surgeries performed on the wrong body part, or incorrect surgical procedures performed. Another risk involving surgeries includes retained objects, or surgical tools such as towels or sponges being accidentally left inside a patient's body. According to a 2007/2008 medical report on never events in Minnesota, 12 percent of reported events involved retained objects, 7 percent involved wrong-site surgeries, and 5 percent involved the wrong procedures being performed.
Medical products and devices also contribute to never events. Risks include medical machines and tools being used incorrectly or for purposes other than those intended. This category also extends to hazards from medication and other drugs, which can become contaminated and pose risks or harmful side effects. Harm that occurs during a procedure that uses MRI (magnetic resonance imaging) technology is categorized as a radiologic event.
Patient harm that occurs due to the physical surroundings of a health care establishment falls under the category of environmental never events. During care, patients may receive burns or electric shocks that can cause death or serious injury. In addition, lines carrying oxygen or other gases may be contaminated or used incorrectly and result in various hazards. Sometimes, even seemingly innocuous environmental features such as bedrails employed improperly could contribute to never events.
Health care providers have a responsibility to provide reasonable protection to their patients. Failing to do so may lead to never events in the patient protection category. These events may occur if patients are released from care when they are unable to make decisions or if patients disappear from a health care facility. The most serious breach of patient protection involves a patient attempting or committing suicide within a health care facility.
The care management category is also related to patient protection but involves a wider range of cases. These cases may involve errors in medications and prescriptions, failure to communicate test results, or loss or misuse of specimens. According to the Minnesota study, the most common care management event (at 39 percent of all reported cases) involved pressure ulcers or
bedsores
, serious skin injuries that often occur among bedridden people who are neglected by caretakers. Patients sustaining injury or death during falls accounts for 30 percent of cases. These also are part of the care management category. Serious medication errors comprised 2 percent of reported cases.
The final category of never events involves criminal acts perpetrated against patients in health care facilities. These cases may range from sexual abuse to physical assault against patients, as well as abduction of patients. In addition, any actions taken by people falsely impersonating health care personnel such as doctors or nurses fall into the category of criminal events.
Responses and Rarity
Generally, when never events occur, authorities perform a root cause analysis, an in-depth examination of the event and factors that contributed to it. Based on these findings, offenders usually are expected to disclose their errors and officially report them to medical authorities. Offenders typically apologize to patients and their loved ones and waive any costs related to the medical procedure in question. In many events—particularly criminal ones—legal action also becomes an important factor.
Never events can be severe and tragic. Some individuals and organizations have called for stringent standards to eradicate all never events from medical procedures. Despite these strong reactions to never events, medical experts point out that such events are not common. While about four thousand surgical never events take place annually in the United States, that figure should be measured against the millions of procedures medical practitioners perform correctly.
Bibliography
"Johns Hopkins Malpractice Study: Surgical 'Never Events' Occur at Least 4,000 Times Per Year." Johns Hopkins Medicine. Johns Hopkins University, Johns Hopkins Hospital, and Johns Hopkins Health System. 19 Dec. 2012. Web. 4 Feb. 2015. http://www.hopkinsmedicine.org/news/media/releases/johns_hopkins_malpractice_study_surgical_never_events_occur_at_least_4000_times_per_year
Lembitz, Alan, and Ted J. Clarke. "Clarifying 'Never Events' and Introducing 'Always Events.'" Patient Safety in Surgery. National Center for Biotechnology Information, U.S. National Library of Medicine. 2009. Web. 4 Feb. 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2814808/
"Never Events." AHRQ Patient Safety Network. U.S. Department of Health & Human Services. Dec. 2014. Web. 4 Feb. 2015. http://psnet.ahrq.gov/primer.aspx?primerID=3
"Sentinel Event." Joint Commission. Joint Commission. Web. 4 Feb. 2015. http://www.jointcommission.org/sentinel_event.aspx
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