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Understanding "Never Events" and the Disturbing Consequences

medical-hospital_996911-768x511.jpgA recent news story discussed a horrific event that occurred at the Nair Hospital in Mumbai, India. Rajesh Maru, age 32, was killed when he was sucked into a hospital MRI machine when visiting a relative. Maru entered the MRI room carrying a large metal oxygen cylinder, which was dragged toward the MRI by overwhelming magnetic force. When the cylinder struck the machine, it released a lethal amount of liquid oxygen that killed Maru. 

Deepak Deoraj, a local spokesman for the police department, says two staff members have since been arrested according to the penal code for negligently caused death.

This incident is classified as a "never event," which is a medical error that should never happen. These errors come in many varieties, most commonly through:

  • Surgical Error. There have been instances where surgery was performed on the wrong part of the body, such as replacing the left knee instead of the right. Another surgical never event is when the wrong patient undergoes a procedure intended for another patient. A more common error is when a foreign object such as a needle, sponge, or surgical tool is unintentionally left behind within a patient's body.
  • Product or Device-Related Error. Patients can incur severe injury or death from contaminated drugs, tools, or medical devices. A hospital may begin purchasing a different model of a medical device that has functional differences that could lead to a major injury. For example, a faulty PCA pump could inject an excessive amount of pain medication into the patient, causing sudden death.
  • Patient Protection Error. A mistake may be made involving the provider's duty to care for patients. Incidents have occurred where a patient who was mentally unaware or incoherent was discharged from the facility and quickly caused himself severe harm. A lack of monitoring or supervision can lead to patient elopement, where a patient "escapes" from the facility; or a lack of screening, assessment, and monitoring could result in patient suicide.
  • Care Management Error. Errors in care management usually involve medications. A patient could be given the wrong medication or an incorrect dosage, which could lead to allergic reactions, a drug interaction, or an overdose. Another common problem can occur when key test results are not communicated to a medical provider, which can lead to a failure to diagnose a severe condition or abnormality.

How Common Are Never Events?

Never events are "relatively" rare. For example, studies suggest that wrong-site surgery is unlikely to occur at a facility more than once every five years. Overall, the Joint Commission in 2013 estimated that over 4,000 surgical "never events" occur in the U.S. annually. However, in 2016, Johns Hopkins Medicine released a study estimating that a staggering 250,000 deaths occur per year due to medical mistakes, making them the third-leading cause of death in the United States.

Due to the devastation caused by never events, medical providers are now under increasing pressure to prevent them from occurring. These events are now subject to public reporting, in part to heighten overall accountability. Thus far, 11 states require such incidents to be immediately reported and another 16 states have some form of lesser reporting requirements.

What Hospitals Should Do After a Never Event

The Leapfrog Group is a nonprofit industry advocate that promotes hospital accountability and transparency. After years of analysis, the organization published eight steps that hospitals should follow after a never event occurs:

  • Issue an apology to the patient and family.
  • Waive any costs associated with the incident and costs for follow-up care.
  • Report the incident to an outside agency.
  • Conduct an investigation to determine the cause of the event.
  • Seek feedback from patients and families to help determine causes.
  • Notify the patient and family of findings and steps for preventing further incidents.
  • Offer support to the medical personnel involved in the event.
  • Conduct an annual performance and compliance review.

Leah Binder, president of the Leapfrog Group, says that never events should be prevented; if one does occur, hospitals should adopt "the most humane and ethical approach."

However, that's not the current state of things. Roughly 20% of U.S. hospitals do not specifically address "never events" as part of their policies. Compliance rates seem to vary from state to state, with the states in the Southeast and Midwest being the least compliant.

If you or a family member suffered a never event during your medical care, we know what you're going through. At Norton & Norton, P.C., we've handled many medical malpractice lawsuits that involved never events. For a free consultation with a Kansas City never event attorney, please call us at (816) 607-4750.

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