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“Never Events” in Hospitals Should Never Happen, But Should Be Reported
When patients are injured or die accidentally during hospital stays, these incidents are rarely reported or publicized. The public needs to know how and why people were injured while hospitalized.

When patients are injured or die accidentally during hospital stays, these incidents are rarely reported or publicized. Hospitals call these “never events,” because they should never have occurred in the first place. While some of these adverse events may be inadvertent, many are caused by the negligent acts of hospital medical and staff personnel. The general public and future patients deserve to know the circumstances about how and why people were injured while hospitalized, so they can make informed decisions about their care.

Never and Adverse Events

Never events, which are negligent acts causing one type of adverse event, are events that “should never occur in a healthcare setting.” The U.S. Department of Health and Human Services, which houses the Office of Inspector General (OIG), says patients experience this kind of adverse event when their injuries are serious, can be diagnosed and measured and could have been prevented. Examples of never events include wrong-site surgeries, suicide, operative complications, delayed diagnoses or treatment, prescription drug errors and falls.

Patients Suffer Severe Injuries

A report published by the OIG in November of this year estimated that 13.5 percent of Medicare patients who stayed in hospitals during one month experienced some type of never or adverse event. Of the 134,000 patients observed for the report, approximately 15,000 died. According to the most current statistics published by the Agency for Healthcare Research and Quality (AHRQ), there were more than 6,400 never events reported in 2009.

These types of negligent acts are often rare for a particular hospital, typically only occurring once in a 5 to 10 year span. However, when they do happen, never events cause severe harm or death to patients, with around 70 percent proving fatal. This can signify major problems within a hospital or other healthcare facility’s processes, personnel or overall quality control. It is difficult for patients to know the details of these events, however.

Public Never Knows About Never Events

It is important for patients to know about the safety practices and quality of care at hospitals, but there are many reasons why never events go unreported. The federal Patient Safety and Quality Improvement Act of 2005 sought to keep reports of never and adverse events to patient safety organizations confidential. This tactic was a means to encourage reporting by hospitals and other healthcare facilities, but there is not requirement to report.

Advocates for the law say that many more never and adverse events would go unreported if this information was published. Hospital administrators also fear lawsuits and the threat of scaring patients away by making these reports public. Opponents claim these harmful incidents go unnoticed and the personnel, hospitals or other medical facilities responsible for patient adverse events and injuries are never held accountable for their actions.

Improving Hospital Reporting

Both state agencies and patient safety organizations continue the quest for better reporting of adverse and never events. Some states, like Minnesota, are attempting to bring more transparency by publishing reported adverse events online, indicating the hospitals where they occurred. While there are no mandated adverse or never event reporting requirements in place, hospitals should be held responsible for the pain and suffering, medical expenses or wrongful death of patients who experienced adverse or never events under their care.

If you are a patient who was injured during a recent stay at a hospital or medical facility, contact a local personal injury attorney with experience in medical malpractice litigation to discuss your legal rights and options for compensation.

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