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AHRQ on “Never Events” in Hospitals

The Agency for Healthcare Research and Quality is a component of the U.S. Department of Health and Human Services focused on improving medical care across the country. The entity runs the Patient Safety Network which often provides helpful information about efforts to minimize errors and provide better patient care.

For example, PSNET includes a very helpful primer on “never events”–the medical errors that are virtually always preventable with basic safety steps. There is simply no excuse for them ever occurring. The primer explains how the term “never event” was first coined in 2001 and has been used widely in the following decade. Throughout that time the term has expanded in meaning. While initially it referred to truly shocking events (i.e. amputating the wrong body part), it now refers to all errors which are clearly definable, serious, and usually preventable.

Today, the National Quality Forum (NQF)–the entity which coined the phrase–lists 29 different errors as never events. That group is further subdivided into 6 categories including surgical errors, environmental problems, care management mistakes, and more.

Most Common Never Events
Using data from the Joint Commission website, the primer includes a few helpful charts which provide information on which errors are most commonly reported. It is important to keep in mind that these raw totals are not to be taken as gospel. As we have frequently pointed out, there are questions about the reliability of reporting requirements. It is fair to say that most estimates are actually underestimates, because many problems may not actually make it into this Joint Commission data. Still, the comparisons are helpful in providing perspective on which errors need the most attention.

According to the data, wrong-site surgeries are most commonly reported to the Joint Commission. This refers not just to operating in the wrong location on a patient’s body but also operating on the wrong patient, or performing the wrong type of operation in the right location on the proper patient. Many are still shocked when made aware of the prevalence of this problem. Surgeries are always delicate and risky, and one assumes that the basics–the right person, the right operation, in the right spot–would always be handled correctly.

Interestingly, the second most commonly reported never event is suicide by a patient. That is followed by preventable post-op complications, treatment delays, medication errors, and falls. One possible explanation for these specific events being the most reported is that they represent some of the most obvious example of errors. For example, it does not take specialized medical knowledge for patients (or their families) to understand that medical malpractice occurred when the wrong operation was performed. Similarly, things like allowing a suicide or not preventing a fall in the facility are clear examples of caregiving lapses. There may be other errors that occur even more often, but if they are hard for the lay person to connect immediately to poor care, they could be reported less often.

Each Chicago medical malpractice lawyer at our firm urges residents to educate themselves on these preventable errors, and to take action if you suspect something like this occurred to you or a loved one.

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