Personal Injury Law

Never Events

By John A. Day

Here are the 28 medical events that the National Quality Forum says should never occur:

Surgical Events

Surgery performed on the wrong body part
Surgery performed on the wrong patient
Wrong surgical procedure on a patient
Retention of a foreign object in a patient after surgery or other procedure
Intraoperative or immediately post-operative death in a normal healthy patient

Product or Device Events

Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility

Patient Protection Events

Infant discharged to the wrong person
Patient death or serious disability associated with patient disappearance for more than four hours
Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility

Care Management Events

Patient death or serious disability associated with a medication error
Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products (transfusion of the wrong blood type)
Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy while being cared for in a healthcare facility
Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
Death or serious disability (kernicterus) associated with failure to identify and treat jaundice in newborns
Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
Patient death or serious disability due to spinal manipulative therapy

Environmental Events

Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
Patient death associated with a fall while being cared for in a healthcare facility
Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
Criminal Events
Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
Abduction of a patient of any age
Sexual assault on a patient within or on the grounds of a healthcare facility
Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

By the way, this group has recently released "Safe Practices for Better Healthcare 2009 Update A Consensus Report."  Here is an abstract of the report.

Improving the safety of healthcare delivery saves lives, helps avoid unnecessary complications, and increases the confidence that receiving medical care actually makes patients better, not worse. Unfortunately, patients are still harmed, or nearly harmed, in healthcare institutions across the country every day. This harm is not intentional, however, and it usually can be avoided. Although modest advances in patient safety have been made nationally since the National Quality Forum (NQF) published its report Safe Practices for Better Healthcare—2006 Update, adverse healthcare events continue to be a leading cause of death and injury in the United States, even though well-documented methods continue to be available that could prevent their occurrence.

Safe Practices for Better Healthcare—2009 Update presents 34 practices that have been demonstrated to be effective in reducing the occurrence of adverse healthcare events. This revised set of NQF-endorsed safe practices has been updated with current evidence and expanded implementation approaches, and it provides additional measures for assessing the implementation of the practices.

Systematic, universal implementation of these practices can lead to appreciable and sustainable improvements in healthcare safety. The update explicitly calls upon healthcare organization leaders and governance boards to review proactively the safety of their organizations and to take action to improve continually the safety and thus the quality of the care they provide.  [Emphasis added.]
 

Full post as published by Day on Torts on April 10, 2009 (boomark / email).