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Inexcusable Medical Mistakes | Daytona Beach Medical Malpractice Attorney

Medical Errors and Results That Should NEVER Occur

Within the medical field, certain results are referred to as “Never Events.” The National Quality Forum (NQF) created a list of such Never Events which consists of medical mistakes that should never happen and other serious preventable negative medical outcomes.

In 2007, Medicare announced its disapproval of these preventable medical errors by refusing to pay for their treatment. Essentially, Medicare is saying that it will not pay for ailments caused by medical providers.

The stance is analogous to a mechanic client refusing to pay the mechanic for a broken radiator when the client brought the car to the mechanic with bad brakes but in the process of repairing the brakes, the mechanic mistakenly damaged the radiator.

The National Quality Forum’s Health Care most recent list of Never Events released in 2006:

Surgical events
Surgery performed on the wrong body part
Surgery performed on the wrong patient
Wrong surgical procedure performed on a patient
Unintended retention of a foreign object in a patient after surgery or other procedure
Intraoperative or immediately postoperative death in an American Society of Anesthesiologists Class I patient
Artificial insemination with the wrong sperm or donor egg

Product or device events
Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the health care facility
Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used for functions other than as intended
Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a health care facility

Patient protection events
Infant discharged to the wrong person
Patient death or serious disability associated with patient elopement (disappearance)
Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a health care facility

Care management events
Patient death or serious disability associated with a medication error (eg, errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)
Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products
Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility
Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility
Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
Stage 3 or 4 pressure ulcers acquired after admission to a health care facility
Patient death or serious disability due to spinal manipulative therapy

Environmental events
Patient death or serious disability associated with an electric shock or electrical cardioversion while being cared for in a health care facility
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
Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility
Patient death or serious disability associated with a fall while being cared for in a health care facility
Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility

Criminal events
Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider
Abduction of a patient of any age
Sexual assault on a patient within or on the grounds of the health care facility
Death or significant injury of a patient or staff member resulting from a physical assault (ie, battery) that occurs within or on the grounds of the health care facility.

Thankfully, the majority of these Never Events rarely occur. However, Stage 3 or 4 pressure ulcers are still too common especially in the nursing home population.

Of the 312 Never Events reported in Minnesota in 2007-2008, 39 percent, or 112, were pressure ulcers or bed sores. The second most common Never Event was falls, which accounted for 30 percent of the state’s Never Events. These two events occur more often in our elderly population and in nursing home settings and can have deadly consequences.

Less common events include patients receiving the wrong surgery (5 percent) or the correct surgery at the wrong site (7 percent). Though rare, Never Events can be devastating. In fact, 71 percent of reported events over more than a decade have been fatal.

Because these outcomes are so serious and preventable, some states are fighting back. Florida is among 27 states that require serious adverse medical events to be reported. Without an understanding of the magnitude of the problem, Never Events cannot be combated. Though such reporting programs have been criticized, they represent a step in the right direction.

When California released its compilation of reported Never Events to the public, we learned a little more about how such mistakes occur. The disclosure revealed one incident involving a hospital technician who misapplied a ventilator hose which caused an infant to receive inadequate oxygen.
One patient had the wrong surgery entirely because hospital technicians accidentally put the wrong CT scan in that patient’s file. That person’s perfectly good appendix was removed as a result.

Lastly, an elderly patient died because her nurse administered her two drugs that she had not been prescribed. To learn more about each type of Never Event, you can click on the list above.

For more on hospital safety issues, see the library of articles by Daytona Beach medical malpractice attorney.


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