Never Events

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Never events :

Never events Never events are 28 occurrences on a United States list of inexcusable outcomes in a health care setting. The list was compiled by the National Quality Forum . They are defined as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability.“ [ "Half of US hospitals reporting to Leapfrog say they won't bill for a “never event”" . The Leapfrog Group. September 26, 2007. http://www.leapfroggroup.org/media/file/Release_-_Adoption_of_Leapfrog_Never_Events_Policy_2007.pdf ]

Law and Never Events:

Law and Never Events Several states have enacted laws requiring the disclosure of never events at hospitals and various remunerative or punitive measures for such events. A recent Leapfrog Group Study finds that roughly half of the 1,285 hospitals that responded to their survey waive fees for never events, and that hospitals that do waive fees are much more likely to have perfect scores on the Leapfrog Safe Practices Score survey. [ Serious Reportable Events (SREs): Transparency & Accountability are Critical to Reducing Medical Errors" . National Quality Forum. October 1, 2008. http://www.qualityforum.org/pdf/news/prSeriousReportableevents10-15-06.pdf . Retrieved October 19, 2010]

28 Never Events:

28 Never Events As defined by the National Quality Forum and commonly agreed upon by health care providers, the 28 never events are: 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 associated with 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

28 Never Events:

28 Never Events As defined by the National Quality Forum and commonly agreed upon by health care providers, the 28 never events are: 11. Intraoperative or immediately post-operative death in an ASA Class I patient 12. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility 13. Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended 14. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility 15. Infant discharged to the wrong person 16. Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility 17. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility 18. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility 19. Death or serious disability ( kernicterus ) associated with failure to identify and treat hyperbilirubinemia in neonates 21. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility

28 Never Events 21-28:

28 Never Events 21-28 As defined by the National Quality Forum and commonly agreed upon by health care providers, the 28 never events are: 21. Patient death or serious disability due to spinal manipulative therapy 22. 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 23. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility 24. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility 25. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider 26. Abduction of a patient of any age 27. Sexual assault on a patient within or on the grounds of the healthcare facility 28. 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

Recommended actions following a never event :

Recommended actions following a never event The Leapfrog Group offers four actions as industry standards following a never event: apologize to the patient report the event perform a root cause analysis waive costs directly related to the event [Factsheet Never Events" . The Leapfrog Group. March 27, 2008. http://www.leapfroggroup.org/media/file/Leapfrog-Never_Events_Fact_Sheet.pdf . Retrieved October 19, 2010.]

Never Events:

Never Events 1. In Indian Medical Association vs VP Shantha 1995 (6) SCC 651 (vide para 37) it has been held that the following acts are clearly due to negligence: (a) Removal of the wrong limb (b) Performance of an operation on the wrong patient (c) Giving injection of a drug to which the patient is allergic without looking into the outpatient card containing the warning (d) Use of wrong gas during the course of an anesthetic, etc. 2. In Spring Meadows Hospital v. Harjol Ahluwalia SC/1014/1998 : (1998) 4 SCC 39: “Gross medical mistake will always result in a finding of negligence. Use of wrong drug or wrong gas during the course of anaesthetic will frequently lead to the imposition of liability and in some situations even the principle of res ipsa loquitur can be applied.”

Foreign body left:

Foreign body left In Nihal Kaur vs Director, P.G.I.M.S.R. (1996) CPJ 112 a patient died a day after surgery and the relatives found a pair of scissors utilized by the surgeon while collecting the last remains. The doctor was held liable and a compensation of Rs. 1.20 lakhs was awarded by the State Consumer Forum, Chandigarh.

Mop in the abdoman:

Mop in the abdoman In Achutrao Haribhau Khodwa and Ors . vs State of Maharashtra and Ors . (1996) 2 SCC 634 the Court noticed that in the very nature of medical profession, skills differs from doctor to doctor and more than one alternative course of treatment are available, all admissible. Negligence cannot be attributed to a doctor so long as he is performing his duties to the best of his ability and with due care and caution. Merely because the doctor chooses one course of action in preference to the other one available, he would not be liable if the course of action chosen by him was acceptable to the medical profession. It was a case where a mop was left inside the lady patient’s abdomen during an operation. Peritonitis developed which led to a second surgery being performed on her, but she could not survive. Liability for negligence was fastened on the surgeon because no valid explanation was forthcoming for the mop having been left inside the abdomen of the lady. The doctrine of res ipsa loquitur was held applicable ‘in a case like this’. [334/2005/SCI/ 144-145 of 2004: Jacob Mathew vs State of Punjab and Anr : 5th day of August 2005: R C Lahoti , CJI: Hon’ble Mr. Justice G P Mathur , Hon’ble Mr. Justice P K Balasubramanyan ]

Never Events:

Never Events There may be cases which do not raise such complicated questions and the deficiency in service may be due to obvious faults which can be easily established such as removal of the wrong limb or the performance of an operation on the wrong patient or giving injection of a drug to which the patient is allergic without looking into the out patient card containing the warning as in Chinkeow v. Government of Malaysia (1967) 1 WLR 813 P.C. or use of wrong gas during the course of an anesthetic or leaving inside the patient swabs or other items of operating equipment after surgery. One often reads about such incidents in the newspapers. The issues arising in the complaints in such cases can be speedily disposed of by the procedure that is being followed by the Consumer Disputes Redressal Agencies and there is no reason why complaints regarding deficiency in service in such cases should not be adjudicated by the Agencies under the Act. [ SC/ 4119 of 1999 and 3126 of 2000, 14.05.2009, N izam Institute of Medical Sciences Vs. Prasanth S. Dhananka and Ors.: B.N. Agrawal , Harjit Singh Bedi and G. S. Singhvi , JJ. ]

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