“Never events” are mistakes the National Quality Forum says should never happen during a patient’s hospital stay. The NQF calls these events “serious, largely preventable, and of concern to both the public and health-care providers.”
Starting in October 2008, Medicare and some private insurers will no longer pay for additional costs associated with these “never events”—many experts believe this will give the (financial) incentive needed for hospitals to clean up their acts.
- Artificial insemination with the wrong donor sperm or donor egg
- Leaving a foreign object (such as a sponge or medical instrument) in a patient after surgery
- Patients disappearing from a room or hospital during treatment
- Medication errors (e.g., errors involving wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration) resulting in death or disability
- Administering incompatible blood or blood products
- Death/disability associated with electric shock or elective cardioversion (used to restore an abnormal heart rhythm back to a normal one)
- Falling while being cared for in a health-care facility
- Surgery performed on the wrong body part
- Surgery performed on the wrong patient
- Wrong surgical procedure performed on a patient
- Death during or after surgery in a healthy patient
- Death or disability associated with the use of contaminated drugs or devices
- Death or disability associated with malfunctioning equipment or equipment used other than as it is intended
- Death or disability associated with gas embolism, or gas bubbles in the bloodstream getting lodged in the heart, stopping blood from flowing
- Infant discharged to the wrong person
- Patient suicide, or attempted suicide
- Maternal death/disability associated with labor or delivery in a low-risk pregnancy
- Death/disability associated with hypoglycemia (the onset of which occurs while the patient is in a health-care facility)
- Death/disability after hyperbilirubinemia (or jaundice) isn’t identified in newborns
- Developing bedsores (or pressure ulcers) after admission to a health-care facility
- Death/disability due to spinal manipulative therapy (treatments for low back pain)
- Receiving the wrong gas or a contaminated substance from a line intended for oxygen or other gas
- Being burned from any source while in a health-care facility
- Death/disability associated with the use of restraints or a bed rail during a stay in a health-care facility
- Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other health-care provider
- Abduction of a patient of any age
- Sexual assault on a patient within or on the ground of the health-care facility
- Death or injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds of the health-care facility
By Kimberly Holland
Related Links:
Comments (4)
Being Burned by any source while at a hospital is considered a “Never Event”. My mother was set on fire during surgery. I NEVER thought this could happen at a hospital. I founded SurgicalFire.Org to help educate the public and consumers on the dangers of Operating Room fires Surgical Fires are 100% preventable through education of all staff members of each hospitalm, surgical center, and any other place that uses laser, cautery, or any electric source.
Please visit http://www.SurgicalFire.Org and help spread the word.
As a health care professional for the last 27 years across a variety of health care settings, I find some of your “never shoulds” misleading. I have had patients contribute to their own falls after surgery when they get out of bed without assistance or fail to wear non-skid footware despite my stern warnings and frequent instruction. Back in the day when patients could smoke in a health care facility, I witnessed a burn and accidental death after a patient’s family member failed to return a suicidal patient’s cigarettes to the nursing unit as policy required. This patient went on to set herself on fire and died later in the ICU despite being on suicide precautions that included irregular-interval checks by staff. And I won’t even describe the stupidity of patients who falsify their medical histories by failing to disclose illnesses even when specifically asked about them. My office intake forms now include a statement that the patient verifies the health information is correct to the best of their knowledge and that I am blameless if injury or disability results from their omission or presentation of misleading information that would lead me to create a treatment plan that is not valid (based upon the false information)–which they put their signature to. I think to make a list of “never shoulds” fosters unrealistic expectations about contributory negligence and unnatural responsiblities on providers in an already litigiously preoccupied culture. It also ignores the basic principles of tort and liability law. Health care is already difficult enough without adding fire to the fuel with articles like this.
Kara,
You’re blissfully ignorant regarding the dangers in hospitals. “Never Events” are a social attempt to highlight some of the many failures in our healthcare system that are harming or killing our fellow countrymen. “Never Events” may not be the end-all solution but it’s definately a step in the right direction, for so many reasons.
If you are really a healthcare professional with 27 years’ experience, then you KNOW how dangerous our healthcare system is, either that or you haven’t been paying a lick of attention to your patients in all these years. In the examples you cite re: falls, burns, you’re blaming the pt and/or their family when in realty adequate safety/staffing/supervision/pt education can and will prevent these outcomes.
I’m not sure how my insurer refusing to pay for never events helps me. My local hospital will have my house if they don’t get paid. Or I can hire an attorney and go through the stress of a lawsuit to get the billing department off my back. I would like to know if there’s a provision in this policy for not allowing the health care vendor denied insurance payment to bill the patient.