Never Event Blog
A “Never Event”* is a clearly identifiable and measurable, serious, and usually preventable medical error or event. “Never Events” fall into a variety of categories and consists of medical errors such as bedsores, wrong-site surgery and medication errors. If you suspect you or a loved one are victims of medical malpractice, negligence or nursing home abuse, please contact us today to speak to an attorney. Our goal is to make sure that your patient rights are protected and that medical professionals and facilities are held accountable for their actions.
The term “Never Event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors that should never occur. Over time, the list has been expanded and grouped into six categorical events: surgical, product or device, patient protection, care management, environmental, and criminal. Source: http://www.psnet.ahrq.gov/primer.aspx?primerID=3
Hospital ER’s negligence leads to nurse’s disfigurement
A local 39-year-old mother of two lost both legs, all of her fingers on both hands and suffered disfiguring injuries to her face. Jean Law can no longer live any part of the life she had before she sought treatment this past February from the ER at Baptist Hospital South. She suffered a high fever, chills, nausea, pain and difficulty in walking, common symtoms of sepsis that went undiagnosised.
Jean Law knew her symptoms were serious – she had been a nurse with Baptist Hospitals for 17 years and on duty at Baptist South for the past five years. Her temperature, was at the dangerously high level of 104.6. This and her other symptoms are consistent with serious bacterial infection. Although the ER treating Doctor ordered blood and urine tests, after approximately five hours, he diagnosed a viral flu, prescribed Motrin and discharged Law to go home. Doctor's notes from this interaction state, “…serious causes have been ruled out, and there is no indication that she needs antibiotics.” Because of his diagnosis, Law was neither admitted to the hospital nor treated with any type of antibiotic treatment.
Law and her husband Jonathan were surprised and confused. As a nurse, she had expected to.... Read more...
BCBS & Never Events
The Blue Cross and Blue Shield Association (BCBSA) announced on February 26, 2010 that all 39 independent Blue Cross and Blue Shield companies established a payment policy that prohibits reimbursement to contracted acute care hospitals for hospital acquired conditions or "never events" – serious events or medical errors that are clearly identifiable and preventable.
The Blues policy, which went into effect on Jan. 1, 2010, include 12 preventable events as recommended by the Centers for Medicare and Medicaid Services (CMS). In addition, Blue Cross and Blue Shield companies will not reimburse for surgery performed on the wrong patient, a wrong body part or for a wrong procedure. Blue companies also will assure that acute care hospitals in Blue networks must hold the member harmless for any charges associated with never events. Click Here to read the rest of the BCBS Press.... Read more...
CMS & Never Events
In July of 2008, the Center for Medicare & Medicaid Services (CMS) issued State Medicaid Director Letter #08-004 to provide guidance related to coordination of State Medicaid payment policies with policies recently adopted by the Medicare program. This is needed when hospital providers bill for selected hospital-acquired conditions (HACs). Prompted by the 2002 & 2006 National Quality Forum list of 28 Never Events as well as the study by the Centers for Disease Control & Prevention that found common medical errors total more than $4.5 billion in additional health care spending a year, the CMS concluded that when acquired in hospital setting, these selected conditions will no longer lead to Medicare payment.
The CMS exercised its authority under section 5001(c) of the DRA by announcing that Medicare will no longer pay the extra cost of treating the following categories of conditions that occur while the patient is in the hospital.
- Air Embolism
- Falls and Trauma
- Pressure Ulcer Stages III and IV
- Surgical Site infection after
- Bariatric Surgery Obesity
- Bypass Surgery (Mediastinitis)
- Certain Orthopedic Procedures
- Administration of Incompatible Blood
- Vascular-Catheter Associated Infection
- Catheter-Associated Urinary Tract Infection
- Foreign Object Unintentionally Retained after Surgery
To read the rest of the Director Letter click.... Read more...
Memorial Bed Sore Cases-February 2010
Memorial Hospital faces six lawsuits for related medical negligence "Never Events"
February 23, 2010
Six families are in the process of filing suit against Memorial Hospital for neglect and negligence that allowed patients to contract decubitus ulcers (bedsores) that led to complications ranging from disfigurement to death. The United States Department of Health and Human Services classifies bedsores as a "Never Event." According to the National Quality Forum, "Never Events" are errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients and that indicate a real problem in the safety and credibility of a health care facility.
Bedsores are caused by unrelieved pressure to the skin that cuts off blood circulation to the affected area. Parts of the body where bedsores most commonly develop when a patient is not moved, turned, kept dry and clean or given proper nutrition while confined to a hospital bed, are the sacrum, coccyx, heels, elbows and ankles.
Preventing bedsores is a standard of care universally known by and applied to all medical care facilities in the United States. Although bedsores have been commonly associated with nursing home neglect, studies show that the problem is increasingly being seen in hospitals. A study conducted by the Agency.... Read more...
