What is a Never Event?

I’m Katelyn Holub, an attorney focusing on personal injury law in northwest Indiana.

Welcome to Personal Injury Primer, where we break down the law into simple terms, provide legal tips, and discuss personal injury law topics.

Today’s question comes from a caller who reported that her elderly mother was injured in a hospital. Upon questioning the patient’s daughter we learned that they had given her mother a transfusion of the wrong type blood. The mistake had fatal consequences for the patient.

The type of error involved in the caller’s case is what medical professionals call a “never event”.

“Never events” are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients. These events are also often referred to as “sentinel events.”

Such events indicate a major problem in the safety and credibility of a health care facility.

Examples of “never events” include surgery on the wrong body part; foreign body left in a patient after surgery; mismatched blood transfusion; major medication error; severe “pressure ulcer” acquired in the hospital; and preventable post-operative deaths.

If a “never event” happens at a health care facility, it means usually that the safety systems in place at the facility are broken.

Here are more “NEVER EVENTS” listed by category:

Surgical Events

• Surgery on the wrong body part
• Surgery on the wrong patient
• Leaving a foreign object in a patient after surgery
• Intraoperative or immediate post-operative death in a healthy patient (often this indicates an anesthesia error)
• Prolonged fluoroscopy with cumulative dose >1500 rads to a single field, or any delivery of radiotherapy to the wrong body region or 25 percent above the planned radiotherapy dose

Device or Product Failures

• Death or disability due to the use of contaminated drugs or instruments by a healthcare facility (such as using a dirty scalpel)
• Death or serious disability associated with the use or function of a device that fails to function as intended (an example might be a pacemaker that damages a patient’s heart)

Patient Protective Policy Failures

• Discharging an infant to the wrong person
• Patient elopement (disappearance)
• Patient suicide, or attempted suicide while in a healthcare facility

Care Management Events

• Stage 3 or 4 pressure ulcers acquired in a healthcare facility
• Death or disability flowing from a medication error (wrong drug, wrong patient, wrong dose, wrong time, wrong rate, wrong preparation, or wrong route of delivery)
• Death or disability due to giving incompatible blood products

Criminal Events

• Abduction of a patient
• Sexual assault or physical assault on a patient at a healthcare facility
• Care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other healthcare provider

Environmental Events

• Death or disability due to an electric shock in a healthcare facility
• Any incident in which a line designated for oxygen or other gas contains the wrong gas or is contaminated
• Severe injury or death due to a fall in a healthcare facility
• Death or disability associated with the use of restraints or bedrails

This list is not exhaustive. If a ‘never event’ or ‘sentinel event’ occurs, the organization responsible for the event happenings is supposed to do a thorough and credible root cause analysis and action plan within 45 days of becoming aware of the event.

Failure to do such an analysis suggests that the healthcare facility is experiencing a crisis of management.

We have dealt with a number of these “never events” in assisting our clients over the years.

Just as one example, if a nursing home has one patient who has been allowed to develop stage 3 or 4 pressure ulcers, the odds are high that the facility is failing to properly treat other patients and may require a license forfeiture action by the agency regulating the facility.

I hope you found this information helpful. If you are a victim of someone’s carelessness, substandard medical care, a product defect, work injury, or another personal injury, please call (219) 736-9700 with your questions. You can also learn more about us by visiting our website at DavidHolubLaw.com – while there, make sure you request a copy of our book “Fighting for Truth.”