Clearing Up the Real Consequences of Never Events

As we’ve discussed in many of our blog posts, the expectations of a hospital visit or procedure versus its reality often results in disappointment at best, court cases and mortality at worst. One attempt at boosting patients’ confidence in the modern medical system has been made by various organizations’ endorsement of eliminating “never events.” While never events can be absurdly negligent, others are more questionably so, and the way in which they have been framed over the past decade can give those informed cause for doubt. Here is a basic overview of never events, their prevention, and what has caused many to pause and reconsider when classifying these incidents.

What are never events?

According to the National Quality Forum’s 2011 report, there are 29 events that have been termed “serious reportable events” and, though extremely rare, are medical errors which should never happen to a patient.[1] The list includes events which are largely preventable, and though some indicate obvious negligence – such as the discharge of an infant to the wrong person or transfusion with the wrong blood type – others, such as pressure ulcers or falls, do not. Additionally, the Centers for Medicare and Medicaid Services adopted “never events” in 2008 as “non-reimbursable serious hospital-acquired conditions” in order to create motivation for hospitals to improve patient safety.[2]

 

How have hospitals worked to reduce risk?

Most efforts to reduce never events have focused on education and renewed diligence. The use of surgical checklists, standardized and universally followed approaches, and culture-changing training regarding communication, assertiveness, team training, and briefing have all been helpful.[3] Human factors scientists have been studying the relationship between humans and systems and applying their findings within hospitals to improve efficiency, safety, and effectiveness.[4] As mentioned in our post about the reduction of medical errors, increased vigilance, labeling, and effective communication can go a long way to reduce preventable events.

 

The shortcomings of never events

Ever since CMS brought never events front and center, hospitals have emphasized decreasing the chances of these rare incidents at the cost of greater, more widespread problems.[5] Gauging a hospital’s success by the frequency of never events ignores the increasing complexity and severity of patients’ illnesses, which leaves more patients likely to suffer pressure ulcers and falls, and fails to recognize the new procedures, operations, and treatments that weren’t performed a decade ago.[6] Several have argued that the inclusion of falls on the list of never events is misguided, seeing as there is currently no evidence that hospital falls can be consistently and effectively prevented.[7] Similarly, most wrong-site procedures are associated with abnormal anatomy, and retained foreign objects are mostly miniscule pieces of implantable devices that rarely cause harm, hence why clinicians didn’t bother retrieving them during the procedure.[8] Focusing on measures that supposedly prevent these minor, rare occurrences can cause reallocation of resources from other areas that might have a broader impact on patient safety.[9]

 

How we can reframe our thoughts of care expectations

Never events are framed in an inherently negative way, and because of this, patients and hospitals alike tend to see them as a serious impediment to their wellbeing. One study suggests instead thinking of “always events,” positive affirming behavior that can motivate rather than scare us into improving safety and promoting better outcomes.[10] Examples of such “always events” include patient identification by more than one source, mandatory “readbacks” of verbal orders for high-alert medications, disclosure of adverse outcomes with patients and families, and tracking critical imaging, lab, and pathology results.[11] The Mayo Clinic has been examining all aspect of care, looking for trends to determine the best opportunities for improvement, while adopting advanced bar coding systems, eliminating handwritten prescriptions, and implementing technology that focuses on medication errors, which are much more severe and widespread.[12] Consequently, there was not a single medication error on Mayo’s largest campus for the entirety of 2015.[13]

 

It is true that never events should not be happening, but the real moral of the story is that there are bigger fish to fry in the medical world. If a real difference is to be made in preventing errors and increasing patient safety, hospitals and lawmakers need to be focusing on emphasizing positive reinforcement, not negative.

[1] “Factsheet: Never Events,” Leapfrog Group, April 1, 2016, http://www.leapfroggroup.org/sites/default/files/Files/Never%20Events%20Fact%20Sheet.pdf

[2] Lembitz, Alan and Ted J. Clarke, “Clarifying ‘never events’ and introducing ‘always events,’” National Center for Biotechnology Information, Dec. 31, 2009, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2814808/

[3] Ibid

[4] Morgenthaler, Timothy and Charles M. Harper, “Getting Rid of ‘Never Events’ in Hospitals,” Oct. 20, 2015, Harvard Business Review, https://hbr.org/2015/10/getting-rid-of-never-events-in-hospitals

[5] Ibid

[6] Ibid

[7] Lembitz and Clarke, “Clarifying ‘never events’”

[8] Morgenthaler and Harper, “Getting Rid of ‘Never Events’”

[9] Lembitz and Clarke, “Clarifying ‘never events’”

[10] Ibid

[11] Ibid

[12] Morgenthaler and Harper, “Getting Rid of ‘Never Events’”

[13] Ibid

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