What Are Never Events?
January 11, 2023
Years ago, the National Quality Forum released a list of 29 serious, reportable events involving rare medical errors that should never happen to a patient in a healthcare setting. These events are called “never events.”
According to the Centers for Medicare & Medicaid Services, these medical errors significantly increase healthcare costs. Many states have enacted legislation requiring healthcare providers to report if these events occur. Here is a look at what never events are and the process for obtaining compensation through medical malpractice lawyer if you’re injured by a medical error that should never have happened.
The Types of Errors that Are Considered Never Events
Surgery on the wrong body part. Discharging an infant to the wrong person. Death during a routine, low-risk procedure. It is hard to believe healthcare professionals could make such errors, but they do. Healthcare settings where never events occur can include hospitals, private physician’s offices, outpatient surgery centers, and even long-term skilled nursing facilities (nursing homes). Here are the types of errors that the National Quality Forum has deemed serious reportable events (SREs) or never events.
Surgical or Invasive Procedure Events
Wrong site, wrong patient, or wrong procedure surgeries occur around once in 112,000 surgeries, meaning most hospitals will experience one of these errors every five to 10 years.
Wrong-site surgery involves operating on the wrong body part, such as performing the procedure on the right arm of a patient who needed surgery on their left arm. Wrong patient errors involve performing a scheduled procedure on the wrong patient. These errors often involve two patients with similar names simultaneously at the facility for different procedures. Wrong procedure surgeries involve a mix-up in which the correct patient is on the operating table, but the surgeon mistakenly performs another procedure instead.
Other types of surgical or invasive procedure events that are considered serious and reportable include a foreign object such as a surgical tool, sponge, or towel left in the body cavity after a procedure and errors resulting in the death of a normal, healthy patient during or immediately after surgery.
Product or Device Events
The types of product or device events included on the NQF list of never events are:
- A patient’s death or serious injury caused by the use of contaminated drugs, devices, or biologics in a health care setting;
- A patient’s death or serious injury due to using a device in a health care setting for a purpose other than its intended use; and
- A patient’s death or serious injury resulting from an intravascular air embolism during the patient’s treatment in a health care setting.
An intravascular air embolism involves a bubble of air that gets trapped in a blood vessel and prevents blood from circulating properly. This can occur in several ways, such as a provider failing to remove air from syringes and IV lines before connecting them, improperly inserting or removing catheters and other tubes, or failing to monitor the patient during surgery to ensure air bubbles do not form in their blood vessels.
Patient Protection Events
One type of never event that involves errors in patient protection includes discharging a patient of any age who cannot make decisions for themselves to someone who is not authorized to have that person in their custody.
Another patient error that should never happen, according to the NQF, is a patient being seriously injured or killed because they were permitted to wander away from the health care facility where they were receiving treatment. Additionally, adequate supervision by staff should prevent any patient from committing suicide or attempting suicide at a healthcare facility.
Care Management Events
Several errors can occur during the management of a patient’s care that is considered serious and reportable if serious injuries or death ensue, such as:
- Medication errors, include giving a patient the wrong drug, dosage, rate, time, preparation, or route of administration.
- The unsafe administration of blood products.
- Errors during labor and delivery involving a low-risk pregnancy while the patient is being cared for in a health care setting that result in injury or death to the mother or infant.
- Artificial insemination involves the wrong donor sperm or the wrong egg.
- A patient suffering a fall while in a health care setting.
- The development of stage 3, stage 4, or unstageable pressure ulcers (bed sores) that develop after the patient is admitted to a health care facility.
- The loss of irretrievable and irreplaceable biological specimens results in patient death or serious injury.
- The failure of health care staff to communicate laboratory, pathology, or radiology reports or to follow up with a patient, causing death or serious injury.
Environmental never events involve issues with the facility and equipment used to treat a patient. This category includes patient injury and death resulting from:
- An electric shock during the patient care process in a health care setting.
- Incidents in which a line designated to deliver oxygen or other gas to a patient contains no gas, the wrong gas, or is contaminated.
- Burns from any source while treating the patient in a health care setting.
- The use of restraints or bed rails on a patient in a health care setting.
A magnetic resonance imaging (MRI) machine is a commonly used diagnostic tool in health care settings, allowing medical professionals to not only view the internal anatomy in detail but to distinguish between normal and abnormal tissues.
Instead of using radiation to produce these images as an X-ray would, the MRI machine uses magnetic fields and radio signals, making obtaining the images safer for the patient. However, for patients with medical implants and other metal in their bodies, receiving an MRI can be dangerous, and deaths and injuries resulting from a metallic object in the MRI area is considered a never event.
Potential Criminal Events
According to The Joint Commission, in a 10-year timeframe, the organization received 456 reports from accredited organizations of violent and criminal events resulting in patient injury or death in a healthcare setting, including 249 reports of sexual assault, including rape, 109 reports of physical assault resulting in injury, and 61 reports of homicide, generally from physical assault. Two hundred sixty-one of the reports involved patient-on-patient violence. Eighty-five incidents involved staff-on-patient violence, with the majority being sexual assaults.
Serious, reportable crimes that constitute never events include:
- Care ordered or provided by someone unlicensed or impersonating a healthcare provider.
- Abduction of a patient from a healthcare facility.
- Sexual assault of a patient at a health care facility.
- Death to a patient or staff member as a result of a physical assault occurring on the grounds of a healthcare facility.
Medical malpractice claims are generally filed against the provider’s medical malpractice insurance policy. Medical malpractice insurance is professional liability insurance purchased to protect healthcare providers from liability for injuries and deaths resulting from their decisions, actions, or inactions.
Most states, including Michigan, do not require healthcare providers to obtain a specific amount of medical malpractice insurance. However, most healthcare facilities in the state maintain medical malpractice policies that cover the negligence of the facility itself or the staff it hires. Most doctors maintain their own medical malpractice policy and are required to do so to have privileges in the facilities where they practice.
A medical malpractice victim can file a claim with the facility’s or physician’s medical malpractice insurer. If the insurer fails to offer fair compensation, the claimant can file a lawsuit in civil court. The court system will use a judge or jury to make decisions about liability and compensation.
Michigan has strict deadlines for when you must file a medical malpractice lawsuit, and also requires a notice to be served on the medical providers before this deadline passes. Do not delay and miss your opportunity to seek compensation. No matter your injury, consult an experienced medical malpractice attorney as soon as possible to protect your rights.
How an Attorney Can Assist You After A Never Event Has Injured You
Medical malpractice claims are among the most difficult personal injury claims, as they require extensive medical documentation and evidence. This type of evidence is difficult to obtain and an inexperienced attorney may not even know what type of evidence is needed or where to look for it.
An experienced medical malpractice attorney can assist people who suffered never events in a healthcare setting. The attorney will provide:
- A free case evaluation, in which the injured party can learn more about the claims process and talk with an attorney about the specifics of their case, and obtain answers to their questions without cost or obligation.
- A contingent fee billing method that allows the claimant to wait to pay for the services of their attorney until they’ve received compensation for their claim.
- An extensive investigation and legal analysis were to determine all sources of liability for the medical error that resulted in injury.
- An assessment of the claim’s value, including the expenses incurred by the patient for treatment of the injury and the psychological impacts of the error.
- Filing the claim with the provider’s medical malpractice insurer and managing communication with that insurer to negotiate a settlement that fairly compensates the claimant.
- Filing a medical malpractice lawsuit on behalf of the claimant within the statute of limitations to protect the claimant’s right to use the court process when seeking compensation for the impacts of the error.
- Assistance in receiving and distributing the compensation from a negotiated settlement or court award.
If a medical error has injured you or caused the death of a loved one, contact us to speak with an experienced medical malpractice attorney today. Schedule a free consultation to learn more about your potential right to compensation and how an attorney may be able to help you recover what you deserve.