Question

A very important aspect of healthcare administration is avoiding never events as these are termed. Give an example of a never event, and explain how you would respond to such an event taking place in your own healthcare facility. Also, as hospital CEO, how would you work to prevent never events in your organization moving forward?

Answer 1

Never events are serious medical errors or adverse events that should never happen to a patient. Consequences include both patient harm and increased cost to the institution. Although the preferred terminology reverts to "serious reportable events", this definition may be unlikely be given the prevalence of the viscerally moving term "never event."

An 65 year old male patient was admitted in my hospital, who was diagnosed as carcinoma rectum. He underwent surgery(anterior resection). He developed pressure on sacrum during his postoperative period. He also had a fall in his room. This was a serious situation. For this incident all nursing staff who had taken care for this patient was called for a meeting to analyse where the mistake had happened. I personally meet patient and relatives to know their concern and apologize on behalf of organization. Strict measures will be made in order to stop these types of never events in the institution. Warning letter will be issued to the staffs who are involved in this matter.This matter will be raised in the hospital meeting and staff meeting so that staffs will be aware of these never events in future.

These are the steps that can help to reduce never events in organization

• Including patient identification by more than one source.

• Mandatory "readbacks" of verbal orders for high-alert medications.

• Disclosure of adverse outcomes and transparency with patients and families.

• Medication error reduction strategies.

• Surgical time-out.

• Anesthesia monitoring that is appropriate for the level of sedation.

• Tracking of critical imaging, lab and pathology results.

• Making critical information available at handoffs or transitions in care.