In Virginia, a successful medical malpractice case requires proof of two elements. First, proof the doctor/nurse/hospital/dentist/surgeon, etc. deviated from the accepted standard of care or was negligent. Second, proof the negligence was the cause of the patient’s injuries, harm, or death. Both of these elements are proven by way of testimony from credible medical experts.
But what is a “Never Event?” The term was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.
The current list of 28 Never Events includes:
• Artificial insemination with the wrong donor sperm or donor egg
• Unintended retention of a foreign object in a patient after surgery or other procedure
• Patient death or serious disability associated with patient elopement (disappearance)
• Patient death or serious disability due to 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)
• Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products
• Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility
• Patient death or serious disability associated with a fall while being cared for in a healthcare facility
• Surgery performed on the wrong body part
• Surgery performed on the wrong patient
• Wrong surgical procedure performed on a patient
• Intraoperative or immediately post-operative death in an ASA Class I patient
• Patient death or serious disability due to the use of contaminated drugs, devices, or biologics provided by the healthcare facility
• Patient death or serious disability due to the use or function of a device in patient care, in which the device is used or functions other than as intended
• Patient death or serious disability due to intravascular air embolism that occurs while being cared for in a healthcare facility
• Infant discharged to the wrong person
• Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
• Maternal death or serious disability resulting from labor or delivery in a low-risk pregnancy while being cared for in a health care facility
• Patient death or serious disability due to hypoglycemia which occurs while the patient is being cared for in a healthcare 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 healthcare facility
• Patient death or serious disability due to spinal manipulative therapy
• 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 due to a burn incurred from any source while being cared for in a healthcare facility
• Patient death or serious disability due to the use of restraints or bedrails while being cared for in a healthcare facility
• Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
• Abduction of a patient of any age
• Sexual assault on a patient within or on the grounds of the healthcare facility
• 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
The amazing thing is that we see these Never Events occurring over and over again in the hospitals and nursing homes in Virginia.
Have you or a loved family member experienced a Never Event in a nursing home….or in one of the following hospitals?
Carilion Roanoke Memorial Hospital, Memorial Hospital of Martinsville and Henry County, Danville Regional Medical Center, Stonewall Jackson Hospital, Carilion New River Valley Hospital, Montgomery Regional Hospital, Wellmont Bristol Regional Hospital, Carilion Giles Memorial Hospital, Alleghany Regional Hospital, Carilion Franklin Memorial Hospital, Tazewell Community Hospital, and Lewis-Gale Medical Center