Hospital Never Events in Indiana

Some medical errors are so serious and shocking that they could never occur in a hospital that follows proper safety protocols. Certainly, doctors and nurses have to make difficult decisions every day, and not all patients experience ideal outcomes. To some degree, that is to be expected.

But when medical professionals and hospital supervisors are so careless as to cause highly preventable injuries and deaths, they should be held accountable. We all go to the hospital to get better, and we all have the right to be treated with the accepted standard of care, in a safe environment.

What is a Never Event?

Certain types of medical errors — such as operating on the wrong limb, performing the wrong operation, leaving a surgical tool or foreign body inside a patient, allowing a patient to suffer a fatal fall, or neglecting a patient until they develop stage IV pressure ulcers — should never happen during the exercise of reasonable care. That’s why certain types of medical errors are referred to as “never events”. Such preventable hospital injuries are devastating to patients and their families. Doctors, hospitals, nursing homes and other health care providers in Indiana have a legal duty to follow the recognized standard of care in treating patients.

It is important to realize that there are many different terminologies for never events. For example CMS (Medicare) originally coined the term “never events” to refer to preventable serious adverse events which should not occur in healthcare settings. However, The National Quality Forum now uses the term “serious reportable event” and The Joint Commission on Accreditation of Healthcare Providers (JCAHO) uses the term “sentinel event” to describe essentially the same thing, although in many of its publications it still uses “never event”.

Never Event/Sentinel Event Prevalence in Indiana

There have been efforts in Indiana and nationally to curb the incidence of never events. The Centers for Medicaid and Medicare Services, which administers the Medicare program, announced in 2007 that it would no longer reimburse hospitals for costs associated with many preventable errors, including those procedures listed as never events. This was dubbed the no-pay-for-never-events policy.

Hospitals are supposed to report never events. According to the Indiana Department of Health, health care providers in Indiana reported 111 significant and mostly avoidable medical errors in 2013—the highest number of errors in any year since the state began collecting error reports.

Of the medical errors, 102 errors occurred in hospitals and nine occurred in ambulatory surgery centers. Keep in mind, that these numbers cannot be accurate, as not all never events are actually reported. Here at the Law Office of Kelley J. Johnson, we have dealt with malpractice claims for clients that were never reported by the hospitals.

Error reports are made by health care facility license. For example, Indiana University Health accounted for eight of the reported errors. That encompasses reportable errors from the following facilities, which are under one license: Methodist Hospital of Indianapolis, Indiana University Hospital, Riley Hospital for Children and Saxony Hospital.

In 2009, the federal government expanded the no-pay policy, saying that it would cease making any reimbursement payments to hospitals or doctors for treatment of Medicare patients in the cases of surgery on the wrong body part, surgery on the wrong patient and wrong operations. Here is a snapshot of errors reported in Indiana in the most recent year available:

Sentinel Events in Indiana in 2013

Source: Indiana Medical Error Reporting System

Types of Hospital Never Events

“Never events” include the following:

• Surgical errors. This may involve:
  • Surgery on the wrong body part
  • Surgery on the wrong patient
  • Performing the wrong operation
  • Leaving surgical objects inside a patient
  • Anesthesia complications that lead to death.
• Product or device malfunctions. Doctors and nurses are trained to use their equipment properly and hygienically, but if the equipment malfunctions or is not properly sterilized, it can cause serious injury or death. For example, robotic surgical tools or x-ray machines can cause serious damage if they malfunction.
• Patient protection events. These typically (though not always) involve vulnerable patients such as the mentally ill, the very old, or the very young. An infant might be discharged to the wrong person, or a mentally ill person might commit suicide while unsupervised.
• Care management events. These include one of the most common types of never events—medication errors. If a doctor or nurse administers the incorrect medication, or an incorrect dosage, the patient could die. Blood transfusions of the wrong blood type (which can cause disability or death) also fall under this category, as do preventable surgery or catheter-related infections, maternal injuries in low-risk pregnancies, and severe bed sores. The latest report showed a 50 percent increase in pressure ulcers reported.
• Environmental events. These involve being injured in some way by the hospital environment: Inhaling a harmful gas, being burned by equipment, or falling because of hazardous conditions.
• Criminal events. It seems unthinkable, but medical professionals do occasionally harm their patients on purpose, whether through sexual assault, abduction, or battery. Patients are in a vulnerable position and unable to prevent these attacks.

How Do Never Events and Surgical Errors Occur?

Never events are not simply errors on the part of doctors. Doctors are human, and sometimes make mistakes even when exercising great care. Never events involve disregard for proper safety procedures, inexcusable lack of judgment, systemic failures and even occasionally malicious intent on the part of medical professionals.

The occurrence of never events often points to systemic problems within a hospital. In some cases, it’s the hospital supervisors or administrators who are to blame, as they are responsible for ensuring a safe hospital environment and enforcing safety protocols.

Even if no single individual can be pointed to for causing the injury or death alone, that injury or death may still represent a never event. Surgical sponges are one of the most common retained surgical instruments, some Indiana hospitals have taken steps to curtail these accidents.

Medications that are stored in a drug supply cabinet in such a way as to make it easier for nurses to administer an improper dosage or give the wrong medication point to systemic issues that need correction. Injuries caused by obstacles in a cluttered hallway suggest an issue of lack of maintenance oversight. Hospitals that do nothing to address systemic problems should be held accountable.

Indianapolis Never Event Lawyer Can Help

If you or a loved one has been the victim of a never event medical error in Indiana, help is available. The Indianapolis medical malpractice attorney at the Law Office of Kelley J. Johnson helps families whose loved ones have been victimized by never events in Indiana.

If you suspect that you or a loved one has suffered a preventable medical error resulting in serious harm, please allow us to review your medical records. We work with a forensic nurse and expert physicians to investigate never events so families may receive reliable answers about whether a medical error was preventable and whether a legal claim is appropriate.

Unlike many law firms, the Law Office of Kelley J. Johnson does not charge for having medical experts review your medical records in a malpractice case. If you have been the victim of medical malpractice, you shouldn’t have to incur additional expenses to seek justice.

Contact Us if You Suffered a Never Event

With nearly 20 years of litigation experience, Kelley J. Johnson has the knowledge and skill to hold accountable health care providers who have harmed patients.

Call us today or use our online contact form to have us review your case free of charge.