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Why You Never Want to See a “Never Event” at Your Hospital

By Hardwick & Pendergast, P.S. on February 18, 2019

If you’ve ever gone to a hospital, you’ve had faith in those medical professionals’ skill and commitment to “do no harm.” But there are occasions when doctors, nurses, and healthcare facilities fall short of what is expected of them. Some mistakes are understandable, but others aren’t, and the worst of these are never events.

What Is a Never Event?

The term “never event” was introduced to the medical community in 2001 by Dr. Ken Kizer. Never events are so named because they should “never” happen in a healthcare setting, and there is no excuse when they do. There are seven categories, which include 29 serious reportable offenses. The categories include:

  • Surgical or procedural events: Examples include the wrong surgery performed on a patient, or performed on the wrong body part.
  • Product or device events: Examples include the failure of a medical device, or the use of contaminated drugs or equipment.
  • Patient protection events: Examples include patient suicide, patient disappearance, or discharging a patient while he or she still needs critical care.
  • Care management events: Examples include wrong drug or wrong dose of a drug, unsafe administration of blood, or labor and delivery injuries in a healthy pregnancy.
  • Environmental events: Examples include unintended electric shock to a patient, failure of oxygen source, or wrong gas administered to a patient.
  • Radiologic events: An example would be the introduction of a metal object into the MRI area.
  • Criminal events: Examples include the abduction of a patient, sexual abuse of a patient, or physical assault of a patient.

By definition, never events are preventable, and as such should be eliminated from all healthcare facilities.

Take a Look at the Universal Protocol

An independent nonprofit organization called The Joint Commission has developed a Universal Protocol as a guideline to prevent surgical never events. The Joint Commission oversees and accredits almost 21,000 healthcare organizations and programs in the United State, with a vested interest in improving the medical care of patients.

The main focus of the Universal Protocol is to eliminate wrong-site surgery, wrong patient surgery, and incorrect procedures. The Protocol uses a standard surgical site-marking system, as well as a preoperative checklist and a time-out procedure prior to the incision for any surgery. This system removes the decision-making from a single person and distributes it to multiple medical providers. This is a means of having checks and balances in the process to reduce the potential for human error.

Thousands of surgical never events occur in the United States each year. In some of these cases, the patient was forced to endure a second surgery to perform the correct procedure, but in other cases, the result was truly catastrophic. For example, a 52-year-old Florida resident was admitted to University Community Hospital in Tampa to have his leg amputated. Unfortunately, the surgery was started on his healthy leg, and by the time medical staff realized their mistake, it was too late. He ended up having both legs amputated.

In St. Louis Park, Minnesota, a patient was scheduled to have a kidney removed due to a cancerous tumor. The kidney was removed and sent to a pathologist, who reported there was no tumor in the kidney. Only then was it discovered that the patient’s only healthy kidney had been removed.

One famous case was that of Jesica Santillan, a 17-year-old girl from Mexico who needed a heart and lung transplant. When transplant organs became available, the medical team who performed the transplant assumed someone else had checked the donor’s blood type for compatibility. But no one did, and Jesica received type A organs, though she had type O blood. Her body rejected the transplant, and she passed away from complications. In the final report on the incident from Duke University Medical Center, the hospital attributed the girl’s death to human error.

What Makes a Medical Malpractice Case?

Medical malpractice occurs when a healthcare professional causes injury to a patient through negligence—a breach in the accepted standard of care. When a never event occurs, such as surgery on the wrong body part, the system has clearly failed, and the hospital should be held responsible. There are many medical professionals who are tasked with verifying the patient’s identity and the site of the surgery, and if they don’t do their jobs, they must pay.

If you or a loved one has been forced to endure a never event, contact Hardwick & Pendergast, P.S., at (425) 228-3860. Our Seattle medical malpractice attorneys will work to secure the compensation you deserve. We understand you have suffered both physical and emotional trauma, and we will defend your rights against the hospital’s legal team. Call today so that you can begin to heal while we fight for justice on your behalf.

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