Never Events

They call them never events. The federal government asked the National Quality Forum to help improve health care in this country, and the NQF came up with a list of 27 things (later expanded to 28) that simply should not ever happen if our health care providers are doing what they should. Never events are not mistakes in judgment, or the failure to make a diagnosis that a better doctor would have made, or even allowing a patient to become infected while hospitalized. They are errors in medical care that are clearly identifiable, preventable, and cause serious consequences. They include such things as

  • surgery performed on the wrong part of the body
  • leaving a foreign object in a patient after surgery
  • death of a healthy patient during or immediately after surgery
  • death or serious disability due to a medication error
  • stage 3 or 4 pressure ulcers acquired after admission to a health care facility
  • death or serious disability associated with use of restraints or bedrails

By definition, never events should never happen… but they do. How often? No one knows for sure, because throughout most of the country hospitals are not required to report these events when they occur. In Missouri and Kansas, for example, although efforts have been made to require reporting, reports still are not required.The data from states that require some type of reporting show that never events occur far more often than they should.

  • The Pennsylvania Patient Safety Authority’s 2008 annual report found that wrong-site surgery happens more than once a week in Pennsylvania, and that 194 Pennsylvania patients had foreign objects left in them after surgery in 2008 alone.
  • Minnesota was the first state to require hospitals to report never events. In the year leading up to its 2009 annual report, never events causing serious disability occurred 98 times in Minnesota, and 18 people died from events that never should happen. www.health.state.mn.us/patientsafety/ae/09ahereport.pdf.

We have no reason to believe that Pennsylvania or Minnesota have a higher percentage of problems than other states. In fact, given the attention they pay to the problem it seems likely that they are reducing the problem for patients in their states, and a 2006 study on patient safety in American Hospitals ranked both Minnesota and Pennsylvania as “Best Performers.” See the report at hg-article-center.s3-website-us-east-1.amazonaws.com/a2/e5/5d4e0d9c4b9eafe21705fdda44ba/PatientSafetyInAmericanHospitalsStudy2006.pdf.

In 1999 the Institute of Medicine issued a report estimating that as many as 98,000 people die each year as a result of medical errors. HealthGrades’ 2006 report found over 250,000 potentially preventable deaths between 2002 and 2004. Every year medical errors kill more Americans than drunk drivers, careless drivers, and sleep-deprived truckers combined.