Is your hospital doing everything they can to keep patients safe? Are they keeping track of dangerous Never Events?

When we go to a hospital, we expect to leave in better condition than when we entered. But that is not always the case. Unfortunately, patients can become sicker, and even die, from dangerous mistakes and failures.

Of course, everyone, including medical providers, makes mistakes. And equipment and processes fail. But sometimes these safety issues are so serious and egregious, aggressive steps must be taken by hospitals to prevent them in the first place. And part of that is knowing how, when, and why patients suffer harm from safety related deficits.

Certainly, if hospitals ignore patient safety issues, patients will suffer.

Medical errors and Never Events.

A medical error “is a preventable adverse effect of medical care, whether or not it is evident or harmful to the patient“. Medical errors range from those causing minimal or no patient harm to those causing serious harm or death.

Errors occur more often than you might think. In fact, medical errors are the 3rd leading cause of death in the US, with some experts estimating that errors cause at least 400,000 premature deaths each year in the US.

It’s important to realize that it’s impossible to know the exact number of preventable deaths for 2 reasons: a lack of valid and standardized measures for the major causes of preventable death; and the difficulty separating inevitable from preventable harm.

Today’s blog post focuses on the most serious, harmful medical errors – Never Events.

What’s a Never Event?

Never Events, also referred to as sentinel events, are nightmare scenarios: surgery performed on the wrong body part, or even on the wrong person; medication errors killing or seriously harming patients.

While these two scenarios are scary, there are 27 other Never Events that are just as bad. Never Events are adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.

Although the term was coined in 2002 to reference particularly shocking medical errors, revisions to the list of Never Events expanded to include 29 “serious reportable events” grouped into 7 categories:

Surgical or procedural events
Product or device events
Patient protection events
Care management events
Environmental events
Radiologic events
Criminal events

You can read National Quality Forum’s list of the 29 Never Events here.

How often do Never Events occur?

Although these terrible occurrences are called Never Events, they happen in hospitals across the US. The word “never” refers to how often hospitals and patients want them to happen, not how often they actually occur.

Unfortunately, there is no national system for recording medical errors, including Never Events. Therefore, no one knows how often patients experience harm in hospitals and other healthcare settings.

Yet nearly everyone agrees that medical errors are far too common. Although there is no federal registry, more than 2 dozen states require providers to report “Never Events”, including California, Colorado, Connecticut, Georgia, Maryland, Massachusetts, and Pennsylvania. (See the full list here.)

However, these registries rely on voluntary reporting, which is an unreliable method for collecting patient safety data. For example, researchers found that voluntary reporting missed 90% of adverse events.

But even if the data is accurately reported to the states that require it, it’s nearly impossible for the public to learn the details. Only a few states share facility-specific information with the public, and some don’t share any information with the public.

How do hospitals avoid Never Events?

Although many hospitals have made improvements to reduce Never Events, there is still much room for improvement. Our mothers’ adages about “learning from your mistakes” and “history repeats itself” readily apply to hospitals and patient safety.

It is critical for hospitals to “make aggressive attempts to learn from their mistakes, publicly disclose them, and make every effort to prevent “the mistake from ever happening again.”

How can hospitals reduce the likelihood of Never Events? Hospitals use techniques and process-improvement tools such as checklists, improving technologies, and studying the relationship between people and systems to reduce the likelihood of Never Events.

For example, consider the efforts by Mayo Clinic. Not only do they analyze care outcomes to look for ways to improve, they examine every death in the facility, even expected deaths. Interestingly, when they started reviewing deaths, they found care issues or opportunities for improvements in 23% of deaths.

Years later, that number decreased to 13%, indicating an improvement in patient safety. Additionally, they analyze every safety incident associated with serious harm to determine if staff properly followed their procedures to prevent safety events.

As they learn from their reviews, they updated their standards for safe practices and ensure implementation across the board. These efforts have reduced the frequency of Never Events, although they continuously look for additional ways to improve their practices.

What should hospitals do when/if a Never Event occurs?

The Leapfrog Group, a nonprofit that promotes improvements in the safety of health care, developed a list of 9 steps hospitals should take to ensure that patients and families, as well as caregivers, receive appropriate follow-up if a never event occurs.

A hospital fully meets The Leapfrog Group standards if they agree to follow all of these steps if a Never Event occurs within their facility:

Apologizing to patients and/or families.
Reporting the Event to an outside agency within 10 days of learning of the Event.
Performing a root-cause analysis.
Waiving costs directly related to the Event.
Making the policy available to patients, families, and payers.
Inform the patient and family of the action(s) that the hospital will take to prevent future recurrences of similar events based on the findings from the root cause analysis.
Have a protocol in place to provide support for caregivers involved in Never Events, and make that protocol known to all caregivers and affiliated clinicians.
Perform an annual review to ensure compliance with each element of Leapfrog’s Never Events Policy for each never event that occurred.
Make a copy of this policy available to patients upon request.

How well does your hospital address Never Events?

The Leapfrog Group regularly surveys hospitals to gather data on safety programs and performance. Results of a 2018 survey show that 25.4% of hospitals failed to meet Leapfrog’s standard of 9 steps to take after Never Events.

It is worth noting that not all hospitals choose to participate in the survey. Furthermore, some respond to the survey but don’t answer the questions related to Never Events, making the data from US hospitals incomplete.

You can look up hospitals on The Leapfrog Group’s website to learn if they meet the standard regarding response to Never Events. Search for hospitals by name or location, then scroll down in the “Preventing and Responding to Patient Harm” tab to find the Never Events rating.