What is a “Never Event” in the Health Care Context?

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There are some things that we as health care consumers never expect to happen in the context of the health care we receive. These events are events that should never occur and yet, they do, although their occurrences are rare.

The medical community has a name for such events. Called the “Never Event”, the term initially referred to “particularly shocking medical errors” that should never have occurred. Since the introduction of the term in 2001, it has now been expanded to include adverse medical events that can be clearly identified and measured, are serious – that is, result in death or a serious disability – and are usually preventable.

The list of Never Events, prepared by the National Quality Forum, was last revised in 2011. It now contains 29 Never Events sorted into the following six categories:

  • Surgical events. Surgical Never Events include wrong-site surgery, wrong-patient surgery and retained foreign objects post-surgery.
  • Product or device events. Events falling under this category include death or serious injury resulting from the use of contaminated drugs or where a device was used for an unintended function.
  • Patient protection events. Patient protection Never Events include the suicide of a patient while in the care of a health care facility and patient death or significant injury associated with a patient’s disappearance.
  • Care management events. This is the largest category of Never Events, and includes nine specific events. Never Events falling within this category include death or serious injury resulting from medication errors, unsafe administration of blood products and the failure to follow-up or communicate test results. Artificial insemination with the wrong donor sperm or the wrong egg also falls within the care management events category.
  • Environmental events. Events falling within this category include death or serious injury associated with electric shock in the course of a patient care process, and oxygen or other gas lines delivered to a patient containing no gas, the wrong gas or contamination by a toxic substance.
  • Radiologic events. The sole radiologic Never Event arises from death or serious injury associated with the introduction of a metallic object into the MRI area.
  • Criminal events. This last category of Never Events deals with criminal events, such as care ordered by a person impersonating a licensed health care provider or the abduction of a patient.

While Never Events are fairly rare, they are both devastating to the patient and preventable. Measures have been introduced to try to eliminate them entirely. For example, the Centers for Medicare and Medicaid Services does not pay for costs associated with wrong-site surgeries, nor for additional costs associated with many preventable errors, and several states and private insurers have also adopted similar cost policies.

If you or a loved one has been injured as a result of a medical misdiagnosis and are seeking a qualified medical malpractice attorney, contact Los Angeles doctor-turned-lawyer Bradley I. Kramer for a free consultation today.

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