Medical Errors: A Never Event

A patient that needed a kidney to survive found a perfect match in her brother who agreed to donate.  However, a nurse at a hospital threw away the donor kidney thinking it was medical waste.

I was appalled when I read this, but let us all face it.  The medical community is filled with human beings who will make errors.  It's never did you make an error, it's when did you make an error.  Then I think, did the error harm or have major potential to harm?  Then lastly, what happened to cause the error?  It is very easy to point the finger, though I can say I would have to point the finger at a nurse who threw away an organ; most of the time it is the process.  This case would be termed a "Never Event" as in it should never happen.

So, when you have an error at the pharmacy, what are the steps taken to make sure it is corrected?  Do you have meetings where you discuss the error openly and try to figure out how to correct it?  Or, do you automatically assume that the pharmacist is lazy or needs education?  Do you assume that he/she is incompetent?  Whatever your group does it is so important to step outside of your group and realize that human beings will always err.  Processes must change to create a scenario that has taken into account all of the possible things that could have happened wrong.

Have you ever seen the same type of error or even the same identical error twice from two different medical professionals?  This is a huge red flag that process should be addressed.

The term "Never Event" was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The NQF initially defined 27 such events in 2002. The list has been revised since then, most recently in 2011, and now consists of 29 events grouped into 6 categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal.

Sentinel events most frequently reported* to the Joint Commission. Wrong-site surgery: 867 reports (13.5%), suicide: 770 reports (12%), op/post-op complications: 710 reports (11%), delay in treatment: 536 reports (8.3%), medication error: 526 reports (8.2%), patient fall: 406 reports (6.3%). (*6428 total reports as of September 30, 2009)

Source: Sentinel Event Statistics. September 30, 2009. The Joint Commission Web site.

Distribution of the 312

Source: Adverse Health Events in Minnesota. Fifth Annual Public Report. St. Paul, MN: Minnesota Department of Health; January 2009. Available at: http://www.health.state.mn.us/patientsafety/publications/ consumerguide.pdf. Accessed December 30, 2009.

Table. Never Events, 2011

The National Quality Forum's Health Care "Never Events" (2011 Revision)

Surgical events

Surgery or other invasive procedure performed on the wrong body part

Surgery or other invasive procedure performed on the wrong patient

Wrong surgical or other invasive procedure performed on a patient

Unintended retention of a foreign object in a patient after surgery or other procedure

Intraoperative or immediately postoperative/postprocedure death in an American Society of Anesthesiologists Class I patient

Product or device events

Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the health care setting

Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used for functions other than as intended

Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care setting

Patient protection events

Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person

Patient death or serious disability associated with patient elopement (disappearance)

Patient suicide, attempted suicide, or self-harm resulting in serious disability, while being cared for in a health care facility

Care management events

Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)

Patient death or serious injury associated with unsafe administration of blood products

Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a health care setting

Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy

Artificial insemination with the wrong donor sperm or wrong egg

Patient death or serious injury associated with a fall while being cared for in a health care setting

Any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a health care facility

Patient death or serious disability resulting from the irretrievable loss of an irreplaceable biological specimen

Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results

Environmental events

Patient or staff death or serious disability associated with an electric shock in the course of a patient care process in a health care setting

Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances

Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a health care setting

Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a health care setting

Radiologic events

Death or serious injury of a patient or staff associated with introduction of a metallic object into the MRI area

Criminal events

Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider

Abduction of a patient/resident of any age

Sexual abuse/assault on a patient within or on the grounds of a health care setting

Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a health care setting

From the National Quality Forum

I do think the answer lies in evaluating all errors and making time to do so.  Just sending a report of an error doesn't evaluate why or how it happened.

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