Providers eye ‘never’ events

Edition: July 2012 - Vol 20 Number 07
Article#: 4024
Author: Repertoire

Healthcare providers are working hard to prevent medical errors. Their suppliers can help through the products and services they offer.

Ever since the Institute of Medicine estimated in 1999 that as many as 98,000 people die in hospitals each year as a result of preventable medical errors, healthcare providers have been trying to address the problem. It hasn’t been easy, given providers’ fear of liability, the fragmentation of care (where one provider doesn’t know what another has done to the same patient), and, simply, a lack of attention to the situation. The IOM concluded that the majority of errors aren’t the cause of individual recklessness. “This is not a ‘bad apple’ problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.”

The Washington, D.C.-based National Quality Forum took up the charge, and developed its first list of “Serious Reportable Events in Healthcare,” sometimes called “never events,” in 2002. Since then, NQF has updated these events regularly.

Why report these errors? To learn from mistakes, to share knowledge and to improve patient safety, says NQF. “All who report such events or sponsor reports should recognize and respect the fact that using reports to fix blame is counterproductive in the patient safety improvement effort,” says NQF in its “Serious Reportable Events in Healthcare – 2011 Update: A Consensus Report.”

Last year, NQF recommended 29 events for endorsement as voluntary consensus standards suitable for public reporting. To qualify for the list of SREs, an event must be unambiguous, largely preventable and serious; and it should be indicative of a problem in a healthcare setting’s safety systems.

THE 29 EVENTS ARE:

Surgical or invasive procedure events

• Surgery or other invasive procedure performed on the wrong site.

• Surgery or other invasive procedure performed on the wrong patient.

• Wrong surgical or other invasive procedure performed on a patient.

• Unintended retention of a foreign object in a patient after surgery or other invasive procedure.

• Intraoperative or immediately postoperative/postprocedure death in an [American Society of Anesthesiologists] Class 1 patient.

Product or device events

• Patient death or serious injury associated with the use of contaminated drugs, device or biologics provided by the healthcare setting.

• Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended.

• Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting.

Patient protection events

• Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person.

• Patient death or serious injury associated with patient elopement (disappearance).

• Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting.

Care management events

• Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration).

• Patient death or serious injury associated with unsafe administration of blood products.

• Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting.

• Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy.

• Patient death or serious injury associated with a fall while being cared for in a healthcare setting.

• Any Stage 3, Stage 4 and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting.

• Artificial insemination with the wrong donor sperm or wrong egg.

• Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen.

• Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology or radiology test results.

Environmental events

• Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare setting.

• Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or are contaminated by toxic substances.

• Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a healthcare setting.

• Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting.

Radiologic events

• Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area.

Potential criminal events

• Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist or other licensed healthcare provider.

• Abduction of a patient/resident of any age.

• Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting.

• Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting.

To access the 2011 NQF report, go to http://www.qualityforum.org/projects/hacs_and_sres.aspx