“Never Events”: Will They (N)Ever Go Away?

Maryland Association for Healthcare Quality

October 29, 2009

Health Science Institute

Larry L. SmithVice President, Risk Management, MedStar Health, Inc.

President, MD-DC Society for Healthcare Risk Management

MHA’s Payment Guidelines on Serious Adverse Events

Maryland Hospitals agreed that whenever one of these events result in death or serious disability to a patient the hospital would waive payment for any of the stay:

– Surgery on wrong body part– Surgery on wrong patient– Wrong surgical procedure– Unintended retention of a foreign object– An air embolism that occurs while being treated – A medication error resulting in death, paralysis, coma

or other major permanent loss of function.– A hemolytic transfusion reaction due to administration

of incompatible blood or blood products

MHA’s Payment Guidelines on Serious Adverse Events

In addition, Maryland Hospitals agreed to evaluate on a case-by-case basis whether full or partial payment should be waived for other event that resulted in patient death or serious disability based on:

• Was the error or event preventable?• Was the error or event within the control of the

hospital?• Was the injury to the patient the result of a

mistake made in the hospital?

MedStar’s Adverse Event Reporting SystemWhat is reported

• Serious Safety Harm Report– Any event resulting in death or serious harm– Surgery on wrong body part– Surgery on wrong patient– Wrong surgical procedure– Unintended retention of a foreign object– An air embolism that occurs while being treated – A medication error resulting in death, paralysis,

coma or other major permanent loss of function.– A hemolytic transfusion reaction due to

administration of incompatible blood or blood products

Source: Duke University Medical Center Patient Safety – Quality ImprovementSource: Duke University Medical Center Patient Safety – Quality Improvement

Source: Duke University Medical Center Patient Safety – Quality ImprovementSource: Duke University Medical Center Patient Safety – Quality Improvement

Preventable Errors I Have KnownWrong: • Limb• Side of head (neurosurgery)• Level spine surgery• Patient (cath’ed)• Procedure-right patient

(bunioinectomy v. foot release)• Blood Type• Patient Circumcised• Test results given to patient (AIDS)• Solution used to clean site (100%

acetic acid)• Drug:

– dose – Administration-route

• Organ(s) transplanted• Organ removed

Retained:• Sponge• Kelly Clamp• Needle• Retractor (14” by 3”)• Tip of glove

How should we respond when a patient is injured due to error?

• Disclosure – What? When? Why? Who?

• Apology or Expression of Regret?

• To Bill or not to Bill?

• Discipline or Blamelessness?

Disclosure• Why?

– Right thing to do– Reinforces for staff that transparency is a core value

of the organization and its leadership– Risk management issues are secondary, not

primary……... “the patient may not sue”

• What?– The facts as we know them to be

• When?– As soon as the patient/family is psychologically and

physically ready

Disclosure

• Who:– Requires a situational analysis – often best

done by – or at least in the presence of -someone with a pre-existing relationship with the patient/family

Apology or Expression of Regret?

• Expressions of regret are appropriate for all unanticipated outcomes

• Apology is appropriate when the unanticipated outcome was clearly caused by unambiguous error or system failure