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Never Events and Why They Occur and Why They Should Never Occur

Posted by Alvin Wolff | Sep 06, 2013 | 0 Comments

A never event is an event that occurs in the hospital like a fall, an infection or a wrong sided surgery.  Medicare has gone on record and told hospitals that these events (28) are types of events that should not occur and as such, Medicare will not pay for these events.

I've been in practice now for over 34 years and I've seen thousands of alleged malpractice cases. 

As defined by the National Quality Forum and commonly agreed upon by health care providers, the current list of 28 never events includes:

  1. Artificial insemination with the wrong donor sperm or donor egg
  2. Unintended retention of a foreign body in a patient after surgery or other procedure
  3. Patient death or serious disability associated with patient elopement (disappearance). (like leaving a nursing home)
  4. Patient death or serious disability 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)
  5. Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products
  6. Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility
  7. Patient death or serious disability associated with a fall while being cared for in a healthcare facility
  8. Surgery performed on the wrong body part
  9. Surgery performed on the wrong patient
  10. Wrong surgical procedure performed on a patient
  11. Intraoperative or immediately post-operative death in an ASA Class I patient
  12. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
  13. Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
  14. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
  15. Infant discharged to the wrong person
  16. Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
  17. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility
  18. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
  19. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
  20. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
  21. Patient death or serious disability due to spinal manipulative therapy
  22. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
  23. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
  24. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
  25. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
  26. Abduction of a patient of any age
  27. Sexual assault on a patient within or on the grounds of the healthcare facility
  28. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility

These events are usually caused by systems failures of the institution rather and the negligence of a single individual.

System failures occur due to poor training, poor supervision, sloppy practices and generally not keeping one's eye on the ball.

If you think you've been hurt by a never event, give us a call at 584-4109.  Looking at these cases and helping our clients is what we do best. 

About the Author

Alvin Wolff

Alvin has been in practice for nearly 40 years. During that time, he has handled over 7000 cases and claims and has tried over 100 cases to a jury verdict. Alvin handles all sorts of injury claims, from car crashes, medical malpractice, slip & trip & falls, to dog bites, incorrect prescri...

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