Never Events

November 28, 2011 7:02 AM

The term never event describes when something happens in a medical setting that should never occur. The list of never events (formally called "Serious Reportable Events) released by the NQF includes mistakes such as performing surgery on the wrong body part (or the wrong patient!), or patient suicide while under care. Despite their moniker, "never" events do happen.

Medical services rendered for never events, or for complications resulting from never events, are often non-reimbursable. Insurers will not pay in the case of medical errors.

However, some of the listed never events do not constitute medical errors that could have been prevented. For example, one of the "never events" listed is patient falls. It's argued this is a problem, because unlike other medical errors, falls cannot be necessarily prevented. This has had unintended consequences:

These unintended consequences are likely to include a decrease in patient mobility, an increase in use of physical restraints, and a tendency to focus on measures such as new prevention devices. These can cause reallocation of resources from areas that might have greater impacts on patient safety.

"Never Events", originally a concept in U.S. healthcare, is also employed in the UK healthcare system.

posted by Deathalicious (53 comments total)

Is there a non-gated link to the 4th link - "never" events do happen?
posted by quodlibet at 7:04 AM on November 28, 2011

My mother used to work in Quality Assurance for a pretty large hospital, and this kind of thing happened far more often than "never," so often that they routinely marked the body part to be operated on with a big X.
posted by nevercalm at 7:08 AM on November 28, 2011 [3 favorites]

15. Infant discharged to the wrong person.

28. 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 the healthcare facility.

Seeing as Nr. 15 can only happen in a hospital and Nr. 28 can happen anywhere, it seems strange to find the latter on a list specific to a medical setting.
posted by three blind mice at 7:11 AM on November 28, 2011

Seeing as Nr. 15 can only happen in a hospital and Nr. 28 can happen anywhere, it seems strange to find the latter on a list specific to a medical setting.

A lot of the items on this list could happen anywhere - sexual assault and suicide, for example. The point isn't to isolate types of medical events per se but "things that are preventable, but are so unacceptable that we consider it reasonable to seek to reduce them to zero."
posted by Tomorrowful at 7:16 AM on November 28, 2011 [3 favorites]

My mother used to work in Quality Assurance for a pretty large hospital, and this kind of thing happened far more often than "never," so often that they routinely marked the body part to be operated on with a big X.

I had assumed this was pretty much common practice everywhere but apparently not (or at least it wasn't 5 years ago).

Here's an example of a surgeon who signs his name where he should be operating to make sure that he gets it right and that this problem doesn't occur.
posted by EndsOfInvention at 7:16 AM on November 28, 2011 [1 favorite]

I found a different article with the same subject. Hopefully the mods can substitute it in.
posted by Deathalicious at 7:18 AM on November 28, 2011

Done!
posted by cortex at 7:19 AM on November 28, 2011

Interestingly in my "apparently not" link above, there is a lot of resistance to operation site marking since (among other reasons) unless you do it yourself you can't trust it, and it makes people rely on the marking rather than doing proper final checks.
posted by EndsOfInvention at 7:21 AM on November 28, 2011

From the first link:

The Leapfrog Group offers four actions as industry standards following a never event:

1. apologize to the patient
2. report the event
3. perform a root cause analysis
4. waive costs directly related to the event

Umm, do you think? How about adding these steps:

5. tell the patient the honest and complete truth
6. pay for all medical costs to correct the act
7. take action against the medical staff responsible for event

and realistically:

8. call your insurer
9. call your lawyer
10. get out your checkbook
posted by Muddler at 7:22 AM on November 28, 2011 [4 favorites]

"Never events" happen far too frequently. I get calls from clients all the time regarding medical malpractice issues that have befallen them. In fact, I got a call last week from a man who was put into an MRI machine with a metallic coil implanted in his head... and dangling out of the back of it. Of course, he was in the hospital because he was having issues with condition that necessitated the coil. Yet the providers still put him in the MRI machine.

Sure enough, NQF states:

RADIOLOGIC EVENTS -(NEW) Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area

Yes, never events happen. Based on the calls I get, they happen regularly (though I would not begin to speculate on the error rate based on the total patient population). And I find--anecdotally--that they happen at some hospitals disproportionately more frequently.

Oh... the "marking the limb" stuff doesn't always work either. I have seen where doctors mark the correct limb based on what the chart says, and the chart is wrong. I have seen where the doctors do only right knees in the morning and only left knees in the afternoon and the patient is scheduled at the wrong time. Having the patient mark the limb before they go under is a wise choice because relying on anyone else can result in these errors.
posted by dios at 7:28 AM on November 28, 2011 [2 favorites]

Infant discharged to the wrong person.

Having been present at a non-trivial number of births, I still completely boggle that this can happen. Yes, any system has vulnerabilities. But...they put a paired tag on the mother and the baby literally within seconds of birth and the nurses check those things *obsessively* during the stay and at checkout. In order to give the wrong baby to the wrong person, so. many. things have to go wrong all at the same time. It would be the anti-miracle of birth.
posted by DU at 7:37 AM on November 28, 2011 [3 favorites]

I guess never events are why I had to swear in the presence of witnesses that yes I was the patient admitted with the laceration to my knee, yes it was my left knee, yes I agreed to have the wound stitched up, before they would get started. Even something so seemingly trivial as stitching a wound counts as minor surgery, it seems.
posted by peacheater at 7:39 AM on November 28, 2011

Is this where I mention I've heard that nurses' workloads have dramatically increased over the past years?
posted by benito.strauss at 7:39 AM on November 28, 2011 [15 favorites]

Also known as Massive Lawsuit Events.
posted by monju_bosatsu at 8:05 AM on November 28, 2011 [4 favorites]

Oh... the "marking the limb" stuff doesn't always work either. I have seen where doctors mark the correct limb based on what the chart says, and the chart is wrong. I have seen where the doctors do only right knees in the morning and only left knees in the afternoon and the patient is scheduled at the wrong time. Having the patient mark the limb before they go under is a wise choice because relying on anyone else can result in these errors.

When I had brain surgery, they asked me several times which side was getting the saw, checking each time against their charts. They marked the correct shoulder on the back (the side they were cutting from) with a line. The surgeon was supposed to come in and draw a second line, in a different color, on the side he was prepared to operate on. If they did not form an X (or a reasonable approximation), the surgery would be halted until the entire check in process was repeated without mistake.

My surgery went well, but the next year they had three wrong-side brain surgery incidents (two of them caught before incision). That still kind of bothers me....
posted by GenjiandProust at 8:13 AM on November 28, 2011 [1 favorite]

happened far more often than "never," so often that they routinely marked the body part to be operated on with a big X.

I had to mark an X on my own ankle, with the word YES, and then write NO on the ankle that wasn't being cut.
posted by toodleydoodley at 8:31 AM on November 28, 2011 [2 favorites]

I work as a medical scribe. All day long, I've got doctors' voices in my ears, as they dictate their reports and correspondence.

Not long ago, one doctor was speaking conversationally, not realizing that he'd already connected to our system. This is what I heard, verbatim: "He probably became hypoglycemic and they didn't recognize it. That's why they intubated him and did all this stuff. They could have given him some sugar; he would've been fine. But they killed him."

He was clearly speaking about a local hospital.

And my friends wonder why I avoid doctors.

PS Every med scribe I know feels the same way.
posted by kinnakeet at 8:34 AM on November 28, 2011 [7 favorites]

I recently had my foot operated on and I was surprised by the number of times I was asked to point to which of my feet was the correct one. That was on top of them marking the foot and my leg with a Sharpie. My foot was so messed up a blind person could have figured out which foot was which so it all seemed unnecessary but whatever works, I guess.
posted by tommasz at 8:38 AM on November 28, 2011

Most of these make an abundance of sense. But patient suicide? No, I don't buy that at all. Suicide can be preventable, but it's not in the same category of preventability through caution as amputating the wrong leg or something like that. A self-destructive person will find a way to do so, and I don't really see that as being the hospital's fault all the time.
posted by deadmessenger at 8:40 AM on November 28, 2011

6 - performing major operations with a knife and fork from a seafood restaurant
19 - (near miss - nonfatal) electric shock applied "every five seconds,", wall current
27 - (near miss) deranged knife wielding patient holds staff at bay
25 - abduction of a cadaver to drive in the carpool lane
24 - impersonation of a physician

Two minutes in the life of Dr. Nick Riviera
posted by justsomebodythatyouusedtoknow at 8:41 AM on November 28, 2011 [5 favorites]

I suppose this is why they ask you for your birthday 10,000 times in the hospital?
posted by desjardins at 8:53 AM on November 28, 2011

Suicide can be preventable, but it's not in the same category of preventability through caution as amputating the wrong leg or something like that. A self-destructive person will find a way to do so, and I don't really see that as being the hospital's fault all the time.

I'd be willing to consider off-meds/biochem imbalance-related suicide attempts as in a different category from suicide generally. It may not be something wrong with your life. It may be something medically wrong with you in the moment, and if self-harm is a foreseeable result, then sure this should be a "never event", too.

Could they find a more dramatic name for it? Had I come across this term in a novel, it would have gotten the big ole eyeroll.
posted by Durn Bronzefist at 8:58 AM on November 28, 2011

It's always weird to hold someone responsible for someone else's decision to commit suicide. To say that hospitals must ensure that no patient ever commits suicide is so implausible and unenforceable that it undermines the legitimacy of the whole list.
posted by John Cohen at 8:58 AM on November 28, 2011 [1 favorite]

A recent 'never event' in the news: Doctors aborting the wrong fetus.

Had I come across this term in a novel, it would have gotten the big ole eyeroll.

It seems to come from probability theory.
posted by dhartung at 9:28 AM on November 28, 2011 [1 favorite]

Muddler: your point #7 (take action against the staff involved) is a really bad idea.

We have nearly two centuries of expertise in accident investigation and prevention in the transport sector, starting with railway crash enquiries and now moving into the FAA and equivalent agencies' techniques for investigating air accidents. Just about the first rule of such investigations is: the goal is to identify the cause of the accident so that recurrences can be prevented, not to ascribe blame.

If you go looking for people to blame, (a) you will find them (even if no human being is blameworthy -- because witch-hunts always find witches) and (b) you will give the participants reason to clam up and refuse to cooperate with the investigation.

In general nobody[*] in the medical professions wants to kill or maim a patient; if the purpose of the investigation is to improve safety and make recommendations for new procedures/training where possible, they'll help out.


[*] Dr Harold Shipman aside; but the vast majority of doctors, nurses, pharmacists etc. are not psychopathic serial killers.
posted by cstross at 9:30 AM on November 28, 2011 [11 favorites]

In general nobody[*] in the medical professions wants to kill or maim a patient

You seem to be overlooking the concepts of recklessness and negligence.
posted by John Cohen at 9:55 AM on November 28, 2011

It's always weird to hold someone responsible for someone else's decision to commit suicide. To say that hospitals must ensure that no patient ever commits suicide is so implausible and unenforceable that it undermines the legitimacy of the whole list.

My sister killed herself after leaving a hospital by taking a fistful of meds they had given her that all had the possibility for abuse and overdose, not just anti-depressants. There's holding someone responsible for the decision, and then there's loading, cocking and handing them the gun. You can take great steps to prevent the latter.
posted by nevercalm at 9:59 AM on November 28, 2011 [2 favorites]

In my wife's hospital they call these "sentinel events."

...How about adding these steps:

6. pay for all medical costs to correct the act
7. take action against the medical staff responsible for event

and realistically:

8. call your insurer
9. call your lawyer
10. get out your checkbook

A friend of ours who is a surgeon mentioned that when the hospital contacts it's counsel after one of these events, the first order of business is for the attorney to make a half-joke: "Get out your checkbook. Start writing zeros."
posted by werkzeuger at 10:11 AM on November 28, 2011

Having the patient mark the limb before they go under is a wise choice because relying on anyone else can result in these errors

Exactly. Having the surgeon mark out and sign means the surgeon will perform that surgery on that patient, but it doesn't prevent them from marking out and signing the correct procedure on the wrong patient.

The VA found a simple way to dramatically reduce the class of "incorrect surgery" in non-emergency cases. Before the surgery, as the patient is brought into the OR, and (most critically) before the patient is put under, they ask "Who are you?" and "Why are you here?"

VA providers laughed at this silliness, until, on the second day, they wheeled the wrong guy in, and the surgeon went "Wait, you're not...." and everybody got it. There is a protocol for the mentally confused who might answer incorrectly -- basically, you triple check everything if he gets his name or surgery wrong, but if you're expecting John Smith and you get Bob Doe, you *stop* and assume that everything else is wrong, and you don't cut off that leg.

It's not perfect, but it's surprisingly better than you think. Emergency surgery doesn't work with this, but in the cases of emergency surgery, you often don't know exactly what the procedure is going to be anyway. The class of "unconscious patients undergoing planned surgery" is actually fairly small, and just simply asking who a person is and why they are there can stop a huge number of incorrect surgeries.
posted by eriko at 10:37 AM on November 28, 2011 [4 favorites]

My mother used to work in Quality Assurance for a pretty large hospital, and this kind of thing happened far more often than "never," so often that they routinely marked the body part to be operated on with a big X.

When I have had surgery, they have not only asked me verbally--and repeatedly--what I'm there to have done, and marked the spot with an X, but have asked both me and the surgeon to sign the body part before they transport me to surgery.
posted by not that girl at 10:58 AM on November 28, 2011

John Cohen: you seem to be overlooking the concept of "wants".
posted by cstross at 11:03 AM on November 28, 2011 [1 favorite]

The VA found a simple way to dramatically reduce the class of "incorrect surgery" in non-emergency cases. Before the surgery, as the patient is brought into the OR, and (most critically) before the patient is put under, they ask "Who are you?" and "Why are you here?"

Funny you should mention this. When I was introduced to the various folks who were doing my surgery, I shook each's hand and said, "My name is Ruthless Bunny and I'm here for my surgery."

I read that it was a good idea to do that, so I did.
posted by Ruthless Bunny at 11:34 AM on November 28, 2011

I get injections in my eye every couple of months, and the nurses and doctor always ask me what I am there for and which eye they are working on that day. Their solution is to put a gold star sticker on my forehead above the eye in question, which is somewhat better than writing on my head in Sharpie but makes me feel like I've won a very questionable prize.
posted by zoetrope at 11:51 AM on November 28, 2011 [12 favorites]

I read of an accidental overdose in an infant that provides a good example of why it's a good idea to use a leading zero when writing a decimal amount. The dosage was written as something like ".5 mg", read and provided as "5 mg," and should have been written "0.5 mg."
posted by a puppet made of socks at 12:02 PM on November 28, 2011 [5 favorites]

(NEW) Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen

What does this mean?

When I was introduced to the various folks who were doing my surgery, I shook each's hand and said, "My name is Ruthless Bunny and I'm here for my surgery."

I'm going to steal this and use it all the time, leaving the username intact. I'm Ruthless Bunny, and I'm here for a Venti mocha. I'm Ruthless Bunny, and I'm here for your birthday party. I'm Ruthless Bunny, and I'm here for these batteries and this pack of gum.
posted by longtime_lurker at 12:17 PM on November 28, 2011 [6 favorites]

(NEW) Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen

What does this mean?

A dog ate my transplant heart.
posted by axiom at 12:22 PM on November 28, 2011 [4 favorites]

Biopsy! You need to know what a growth/cancer/alien pod is so that if something else grow in or on the patient, you know if it's a recurring or a new thing. That's why you don't want to dispose of biological material like it's a day-old tuna sandwich.
posted by Lesser Shrew at 12:31 PM on November 28, 2011 [1 favorite]

My grandfather was taken aback when he had an eye op to find he was marked up prominently to make sure they found the right one. He only had one eye.
posted by Segundus at 1:17 PM on November 28, 2011 [1 favorite]

Every surgery I have had in the past 10 years (and they are numerous) involved me signing the correct side, as well as the surgeon doing so. I also am asked my name and birth date constantly. There are other Susan Smiths, one with my same birth date, that live here, but luckily my legal first name is Susan-Jane, which no one else has, so as long as they have it correct we won't get screwed up.

(the only reason I know there is another susan smith in this area with my birth date, is we were in the hospital, on the same floor, with very similar illnesses one time.)
posted by SuzySmith at 2:21 PM on November 28, 2011

This thread must have a reference to The Checklist Manifesto.

Gawande begins by making a distinction between errors of ignorance (mistakes we make because we don’t know enough), and errors of ineptitude (mistakes we made because we don’t make proper use of what we know). Failure in the modern world, he writes, is really about the second of these errors, and he walks us through a series of examples from medicine showing how the routine tasks of surgeons have now become so incredibly complicated that mistakes of one kind or another are virtually inevitable: it’s just too easy for an otherwise competent doctor to miss a step, or forget to ask a key question or, in the stress and pressure of the moment, to fail to plan properly for every eventuality. Gawande then visits with pilots and the people who build skyscrapers and comes back with a solution. Experts need checklists–literally–written guides that walk them through the key steps in any complex procedure. In the last section of the book, Gawande shows how his research team has taken this idea, developed a safe surgery checklist, and applied it around the world, with staggering success.

Gawande is a fantastic writer, btw.
posted by callmejay at 4:21 PM on November 28, 2011 [4 favorites]

Is this where I mention I've heard that nurses' workloads have dramatically increased over the past years?

Indeed, not only have the workloads increased, but it seems like the bulk of the increase has little to do directly with patient care. The nurses I interact with spend as much time documenting things in the electronic medical record (most of which will never be seen by a single person) as they do taking care of patients. In the epilepsy monitoring unit, nurses have been so fixated on doing their required assessments that they have missed that the patient just had a seizure, or that the machine that was supposed to be recording them 24/7 was flashing in big, red letters, "NOT RECORDING."
posted by adoarns at 4:32 PM on November 28, 2011 [4 favorites]

Reading this, I can't believe people would ever choose to have elective surgery.
posted by ThatCanadianGirl at 7:10 PM on November 28, 2011

The Joint Commission, the accrediting body for hospitals in the U.S., mandates a Time Out prior to any procedure to help prevent wrong patient/wrong site surgeries. Atul Gawande's book The Checklist Manifesto has a lot of insight about how difficult it is to get people to actually follow these procedures.

I think the thing people don't realize about surgery is that by the time the surgeon enters the room, typically the patient is entirely covered with opaque sheets, with just a small square of skin showing through a window in the sheets. Even their head is blocked behind drapes. If that knee or head or whatever isn't marked ahead of time, it would be nearly impossible for the surgeon to know that they had the wrong spot just by looking, even assuming they had the right idea in their mind of which side they should be operating on. And of course, there's no way they would recognize at that point that they have the wrong person, not just by looking at what they can see in the surgical field.
posted by vytae at 8:10 PM on November 28, 2011 [1 favorite]

ThatCanadianGirl,
Even if you are in a lot of pain and your joint is destroyed, it is considered
elective surgery. The only non elective surgery is when you have an emergency like a
brain injury or even appendicitis.

So, if you are in enough pain and incapacitated you will opt for elective surgery :) I was blind and getting worse, I elected surgery.
The ones I think are nuts are those that are doing purely cosmetic surgery (that type that does not help function or correct a large disfigurement)
posted by Librarygeek at 1:18 AM on November 29, 2011 [1 favorite]

Derail:

I tend to wake up for brief periods under GA, and while undergoing surgery to fix my shattered right ankle, I woke up feeling a pressure on my left ankle. Alarmed, I quickly raised my hand and shouted, "Wait! It's my right ankle that's broken!"

Long silence.

Finally the surgeon replied calmly, "I know. I just placed a tray on top of your left leg."

Relieved, I promptly fell asleep again.
posted by Alnedra at 5:39 AM on November 29, 2011 [8 favorites]

The only non elective surgery is when you have an emergency like a brain injury or even appendicitis.

Yes, indeed. I did know that at some point. I think reading about pen caps left inside a person after they've been sewn up had me all distracted. So here's hoping I never need any kind of surgery ever!
posted by ThatCanadianGirl at 8:01 AM on November 29, 2011

I just read that studies showed that less than 10% of nurses and doctors washed their hands upon entering a patient's room. "About 1 in 20 hospital patients becomes ill with an infection — many or most of them from the hands of health-care workers. Hospital-acquired infections are the fourth leading cause of death in America." (NYT story) They installed a video monitoring system at one hospital in New York that brought compliance up to 80-90%. I am horrified to think about hospitals that don't have such a system. I personally know 3 people that have died of hospital acquired infections (though I can't prove they were from lack of hand washing).
posted by desjardins at 8:25 AM on November 29, 2011

That list reads like an season of House.
posted by gottabefunky at 10:41 AM on November 29, 2011

Re wrong body part: I always just thought they'd check and see which ass cheek was shaved. I kid. Mostly. I think they marked it with a smiley face. Although come to think of it the smiley face was on the front. Not sure I understand that logic.
posted by thelastcamel at 10:39 PM on November 29, 2011

What blows my mind is that what is standard practice in any manfuacturing/engineering field is appears to be 'new' in medicine. Root cause analysis? QA? Checklists? Does the medial field really consider itself infallible? For example, I would think that after the first couple of malpractice lawsuits due to an item being left in a person, the hospital (or the insurance company backing them) would mandate the use of a check in/check out system for the items which could end up inside somebody. People's lives are at stake, but the procedures and the double checking just don't seem to be there? This is bad.
posted by defcom1 at 6:10 AM on November 30, 2011

I tend to wake up for brief periods under GA, and while undergoing surgery to fix my shattered right ankle, I woke up feeling a pressure on my left ankle. Alarmed, I quickly raised my hand and shouted, "Wait! It's my right ankle that's broken!"

That is not general anesthesia. GA would necessarily imply a tube down your throat. You were sedated.
posted by Mister Fabulous at 10:35 AM on November 30, 2011

For example, I would think that after the first couple of malpractice lawsuits due to an item being left in a person, the hospital (or the insurance company backing them) would mandate the use of a check in/check out system for the items which could end up inside somebody. People's lives are at stake, but the procedures and the double checking just don't seem to be there?

Actually, instrument counts are one thing that they've really gotten good at. All the items available in the sterile field are counted prior to the procedure (2 of these, 4 of those, etc.) and they are recounted and checked against the previous counts several times during the procedure and again after the procedure. If anything gets pulled from a shelf to be added during the procedure, several people have to call out verbally exactly what is being added, and it gets listed on the count list for comparison next time they count. I think they've even added radiopaque lines to the gauze they use during surgery, so anything that was accidentally left in would show up on an xray (metal instruments already would show up, obviously).

The double checking problem for wrong patient/wrong site/wrong procedure thing is an interesting problem, because so much of the solution isn't about checklists or whatever. It's about culture. There's a team of people working together to do surgery, and in theory the surgeon trusts that his team of techs and nurses draped the correct site for surgery. In theory the nurses trust that the surgeon knows that Mr. Jones is supposed to have an appendectomy, not a cholecystectomy. EVERYONE is supposed to know what is being done to whom, but there's not any one person who holds the "buck stops here" responsibility for it. And since it's everyone's responsibility, it's not really anyone's responsibility, unless you work really hard to make that part of your OR culture.

The other cultural element that comes into play is that (overgeneralizing here, but the stereotype exists for a reason) surgeons can be divas. A lot of work has gone into creating a culture where ANYONE can speak up and say "I think something is wrong," and the work has to stop, whether it's the surgeon or the anesthesiologist or the nurse or just the transport guy who wheeled the patient in who is questioning things. Traditionally the surgeon is IN CHARGE, and anyone who has the nerve to question them gets their head bitten off. (They're in charge, but if the wrong site was draped or the wrong patient brought in, you better believe that it was somebody else's fault.) Developing a culture where anyone involved in the patient's care feels not only obligated but also free to speak up if they think something seems amiss, that has been the difficult thing.

Atul Gawande has done a lot of excellent writing on this subject, if anyone wants to learn more about the culture.
posted by vytae at 7:35 PM on November 30, 2011 [1 favorite]

Suicide can be preventable, but it's not in the same category of preventability through caution as amputating the wrong leg or something like that. A self-destructive person will find a way to do so, and I don't really see that as being the hospital's fault all the time

I work as part of the nursing staff at a psychiatric hospital and I can tell you that there are many precautions that are undertaken to insure that suicidal patients don't succeed.

Diligent checks are one way to keep patients safe. Just two weeks ago a colleague found a patient hanging by a bed sheet from the bathroom door. If she had been less diligent in checking the room when the patient didn't respond, he surely would've died.

You may not be able to stop attempts, but you can prevent success, at least in the hospital.
posted by dave78981 at 3:35 PM on December 1, 2011