June 19, 2008

“Never events” are mistakes the National Quality Forum says should never happen during a patient’s hospital stay. The NQF calls these events “serious, largely preventable, and of concern to both the public and health-care providers.”

Starting in October 2008, Medicare and some private insurers will no longer pay for additional costs associated with these “never events”—many experts believe this will give the (financial) incentive needed for hospitals to clean up their acts.

  • Artificial insemination with the wrong donor sperm or donor egg
  • Leaving a foreign object (such as a sponge or medical instrument) in a patient after surgery
  • Patients disappearing from a room or hospital during treatment
  • Medication errors (e.g., errors involving wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration) resulting in death or disability
  • Administering incompatible blood or blood products
  • Death/disability associated with electric shock or elective cardioversion (used to restore an abnormal heart rhythm back to a normal one)
  • Falling while being cared for in a health-care facility
  • Surgery performed on the wrong body part
  • Surgery performed on the wrong patient
  • Wrong surgical procedure performed on a patient
  • Death during or after surgery in a healthy patient
  • Death or disability associated with the use of contaminated drugs or devices
  • Death or disability associated with malfunctioning equipment or equipment used other than as it is intended
  • Death or disability associated with gas embolism, or gas bubbles in the bloodstream getting lodged in the heart, stopping blood from flowing
  • Infant discharged to the wrong person
  • Patient suicide, or attempted suicide
  • Maternal death/disability associated with labor or delivery in a low-risk pregnancy
  • Death/disability associated with hypoglycemia (the onset of which occurs while the patient is in a health-care facility)
  • Death/disability after hyperbilirubinemia (or jaundice) isn’t identified in newborns
  • Developing bedsores (or pressure ulcers) after admission to a health-care facility
  • Death/disability due to spinal manipulative therapy (treatments for low back pain)
  • Receiving the wrong gas or a contaminated substance from a line intended for oxygen or other gas
  • Being burned from any source while in a health-care facility
  • Death/disability associated with the use of restraints or a bed rail during a stay in a health-care facility
  • Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other health-care provider
  • Abduction of a patient of any age
  • Sexual assault on a patient within or on the ground of the health-care facility
  • Death or injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds of the health-care facility

Next: Six Ways You Can Protect Yourself

Back to Your Guide to Preventing Medical Mistakes Intro

By Kimberly Holland

Related Links:
How to Avoid Becoming a Medical Mistake
Skills to Use in the Hospital
Five Surgeries to Avoid

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