Question

In October 2008, legislation was enacted to end “Never Events.” Define “Never Events” and describe at least five of them. What are the ramifications of such a policy (pros and cons)

Answer 1

A "Never Event" is an error that should never occur in medical treatment, which are clearly identifiable and preventable as well as having serious consequences, sentinel events, in patients. These are events that pose a question of credibility and safety of a particular physician and/or hospital. These include:

1. A foreign body such as a surgical instrument left inside a patient after surgery:

This is a never event, which occurs as a result of the surgeon's carelessness. Often this happens in a remote area hospitals with many surgeries and less number of surgeons to attend all those patients. In a hurry, they forget to check for any foreign body left inside the patient before suturing. However, the surgeon's responsibility doesn't allow him to escape by blaming the hospital management or higher-ups for posting him to attend many surgeries.

2. Fatal medication errors:

These are medication errors that are fatal, which can be due to the prescribing physician's mistake, nurse caregiver's mistake, a data error by the medical transcriptionist, etc. These errors are classified as prescription error, dispensing error, omission error, time error, dosage error, unauthorized drug error, wrong drug form error, drug preparation error, deteriorated drug error, administration error, compliance error, monitoring error, etc.

3. Mismatched blood transfusion:

Mismatched transfusions occur when alloantibodies react with the corresponding antigens of the RBC. Hemolytic reactions occur when the patient’s ABO or Rh blood type does not match with the transfused blood. This can be life-threatening as the patient’s immune system will attack the transfused RBC. The ABO incompatibility reaction is caused by the professional’s error. The transfusion of the wrong blood type happens because of incorrect forms, mislabeled blood, or a failure to check the donor’s blood prior to transfusion.

4. Severe bedsores or pressure ulcers acquired during hospital stay:

Patients with mobility issues, prolonged hospital stay, etc get bedsores during because of the careless caregivers. When the patients are bedridden for a prolonged period without much movement, they get bedsores. These bedsores are avoidable with the help of proper caregiving and are caused due to the negligence from the caregiver's part. These severe pressure ulcers can sometimes result in life-threatening conditions.

5. Clearly preventable postoperative deaths:

These postoperative deaths can be due to several issues like inadequate evaluation of the patient prior to surgery, local infection of the surgical site due to insufficient hygiene, medication errors, or any of the above-given never events.

Ramifications of "Never Event" policies can be heard echoing as a more careful attitude in care-giving from the surgeons as well as caregivers. At the same time discouraging to several professionals who saw it as restricting their freedom to deal with the patient. Many professionals were sued on the basis of this such policies meant for patient safety. Many professionals were also sued unnecessarily and were made answerable to somebody else's fault. Though it did not cause much hindrance to those who were following proper guidelines, the glamour of the related professions was slightly affected.