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Report: 1 in 5 Hospitals Falls Short on “Never Events”

In Boston medical malpractice cases, sometimes the term “never events” gets thrown around. It’s a reference to the types of medical errors that health professionals agree should never happen. And yet, they do. Some examples:doctor5

  • Retained surgical instruments (surgical tools, sponges, etc. being left inside a patient after a procedure);
  • Wrong surgery site (a surgeon performs surgery on the wrong limb, body part, person, etc.);
  • Urinary tract infection from a catheter;
  • Pressure ulcers (Stage III and IV);
  • Falls and trauma;
  • Surgical site infections;
  • Medication error fatalities;
  • Administration of incompatible blood;
  • Air embolisms.

Now, a recent study by Castlight-Leapfrog reveals not only are these events occurring, they are happening with alarming frequency. Although there is always some risk a patient incurs with every type of medical treatment. And just because someone suffers a poor health outcome doesn’t necessarily mean medical malpractice is to blame. However, these “never events” are so egregious for the fact that they are deemed entirely preventable. We know what causes them. We know how to stop them. And hospitals should have procedures and policies in place that are strictly followed by staffers to ensure these kinds of things never happen.

And still, they do.

You may recall six years ago the high-profile Boston medical malpractice case involving a Massachusetts General Hospital hand and arm surgeon who went public with details about how he incorrectly operated on the incorrect hand of a 65-year-old woman. Such forthrightness isn’t common. In fact, he issued a seven-page apology to his patient – which is essentially another kind of “never event.” Physicians with the medical industry standard setting organization National Quality Forum praised the doctor’s willingness to come forward.

A landmark study in 1999 by the Institute of Medicine titled, “To Err is Human,” opined that between 44,000 and 98,000 people die in hospitals across the country every year in “never event” medical errors, costing between $17 billion and $29 billion. Subsequent research suggests the latest figures may be double that, despite the fact that we have an even better understanding and greater awareness today of these kind of events.

The Castlight-Leapfrog researchers asserted that when hospitals take a proactive approach to managing these types of events, they are far less likely to occur and may even be eliminated.

The good news is that the agency reported 80 percent of hospitals do have strict protocol in place for how to respond when a “never event” does occur. Those require that hospitals:

  • Apologize;
  • Report error to an outside agency;
  • Perform a root-cause analysis;
  • Waive related costs;
  • Make the policy available.

Massachusetts in particular has a good reputation for this, with 90 percent or more hospitals meeting the industry standards for “never event” policies as of 2015. Nationally, there has been a significant increase in the number of hospitals meeting this standard. It jumped from 53 percent in 1992 to 79 percent in 2012.

Still, sometimes even when a facility has that policy in place, it’s not always followed. Too often, the first concern is shielding the agency from liability from medical malpractice litigation. The concern is that an apology is an admission of liability, which is why many doctors and facilities refrain.

If you have suffered personal injury in Massachusetts, call the Law Offices of Jeffrey S. Glassman for a free and confidential appointment — 1-888-367-2900.

Additional Resources:

One in five hospitals falls short on “never events,” June 9, 2016, By Zack Budryk, Fierce Health Care

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