What Is a Never Event?

Unless you are a medical professional, you are likely unaware of the term “never event.” Never events in healthcare are exactly what they sound like – events that should never occur; egregious and catastrophic incidents during medical treatment that typically leave a patient permanently injured or disabled, or result in death.

Ken Kizer, MD first introduced the term “never event” in 2001, referring to exceedingly shocking medical errors, such as surgeries performed at the wrong site. Per the Patient Safety Network (PSNet), “Over time, the term’s use has expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.”

Since its first definition, the term “never event” has expanded to seven categories:

• Surgical or procedural events. These occur when surgeries are performed on the wrong body part, or even on the wrong patient. Surgical events also include a medical professional accidentally leaving an object inside the patient during surgery, or a normal and healthy patient dying during, or immediately after, a surgery.
• Product or device events. These occur when a device or product used in medical care is contaminated, defective, or used incorrectly, causing the death or serious injury of the patient.
• Patient protection events. These occur when a patient who is unable make decisions is discharged or released to someone other than an authorized person. It can also include deaths or injuries that occur during an “elopement” (the term used to describe the disappearance of a patient), or if a patient attempts to or succeeds in committing suicide or self-harm while in the care of a medical facility.
• Care management events. Care management events include everything from medication errors to maternal deaths to the loss of a baby, as well as “patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results.”
• Environmental events. These events include patient or staff deaths or serious disability due to electric shock, burn injury, toxic chemical exposures, and/or the use of restraints or bed rails during care at a healthcare facility.
• Radiologic events. These include “death or serious injury of a patient or staff associated with introduction of a metallic object into the MRI area.”
• Criminal events. Criminal events can include any care ordered or provided by someone impersonating a doctor, nurse, or any other licensed healthcare provider; if a patient is abducted from or sexually assaulted on the grounds of a healthcare facility; or when a death or significant injury occurs because of the physical assault that happens on healthcare grounds.

While this is a large list of potential events, never events are rare. However, when they do happen, the fatality rate is catastrophic. PSNet reports:

71% of events reported to the Joint Commission over the past 12 years were fatal–and may indicate a fundamental safety problem within an organization. Although individual events are uncommon, on a population basis, many patients still experience these serious errors. A 2013 study estimated that more than 4000 surgical never events occur yearly in the United States.

How can doctors prevent never events?

Never events should never happen, hence their name, but what are medical professionals and facilities doing to prevent these events from occurring in the first place? First, the Centers for Medicare and Medicaid Services (CMS) has made efforts to punish the people responsible for these events by refusing to pay for them. Many other private insurers followed suit, and per PSNet, “since February 2009, CMS has not paid for any costs associated with wrong-site surgeries.”

Second, with recent calls for transparency, never events are now publicly reported in many states across the country – helping hold medical staff and facilities accountable, and improving quality of care. Healthcare facilities are being held responsible for correcting the systemic problems that lead to never events, and some hospitals now require a root-cause analysis whenever a never event occurs.

What if I am the victim of a never event?

If you or a loved one suffer harm because of a never event, you may have a legitimate claim for medical malpractice. When you seek medical care, many professionals are involved in your treatment, and any or all of these people may be held liable when you experience catastrophic and preventable injury. Potential liable parties may include:

• Doctors
• Surgeons
• Nurses
• Physician’s assistants
• Anesthesiologists
• Hospitals and administration
• Lab technicians

The attorneys at Phelan Petty can launch an investigation to determine all responsible parties and work to secure financial compensation for your injuries and losses. We understand the physical and mental devastation these types of malpractice cases cause, both for the patient and their family. We can help.

If you or a loved one has suffered a never event or other serious injury from a medical professional, we urge you to get in touch with the Richmond-based medical malpractice attorneys at Phelan Petty as soon as possible. We can help you navigate the complex litigation process, and fight to recover the compensation to which you are entitled. Call us today at 804-980-7100 or use our contact form to schedule a free consultation. We serve clients in Richmond and throughout Virginia.