Bad Medical Mistakes - The "Never Events"

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(Revised in accordance with Connecticut Department of Public Health Adverse Event Reporting, October, 2012)

The National Quality Forum (NQF) has published a list of "never events"-- serious, preventable medical errors that should never be allowed to occur. The Connecticut Department of Public Health requires reporting of these and some Connecticut-specific adverse events. If you or a loved one has been a victim of a "never event" you may have a medical malpractice claim against the responsible healthcare providers. Our firm assesses potential malpractice cases at no charge, and handles meritorious cases on contingent fees, advancing all costs at our risk in accordance with Connecticut law.

The NQF-Connecticut current list of "never events" as of October, 2012 consists of:

  1. Surgery on the wrong body part.
  2. Surgery on the wrong patient.
  3. Wrong surgical procedure performed on a patient.
  4. Foreign object unintentionally left in patient after surgery.
  5. Death of an otherwise healthy patient during or immediately after surgery.
  6. Patient death or serious injury associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility.
  7. Patient death or serious injury associated with the misuse or malfunction of a device.
  8. Patient death or serious injury associated with intravascular air embolism (injection or introduction of air into the bloodstream).
  9. Infant discharged to wrong person, or discharge of any patient who is unable to make decisions to an unauthorized person.
  10. Patient death or serious injury associated with patient elopement or disappearance.
  11. Patient suicide or attempted suicide, or self-inflicted harm resulting in serious injury while being cared for in a healthcare facility.
  12. Patient death or serious injury associated with a medication error, including wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration.
  13. Patient death or serious injury associated with transfusion of blood or blood product of the wrong type (hemolytic reaction, due to ABO/HLA incompatible blood or blood products), or death or serious injury associated with improper storage or handling of a blood product.
  14. Death or serious injury of mother associated with labor or delivery in a low-risk pregnancy, while being cared for in a healthcare setting, including events within 42 days after delivery.
  15. Death or serious injury of a newborn associated with labor and delivery in a low-risk pregnancy.
  16. Severe (Stage 3 or 4, or unstageable) pressure ulcers acquired in a hospital, nursing home or other healthcare setting.
  17. Patient or staff death or serious injury associated with an electric shock in the course of a patient care process (including elective cardioversion) in a healthcare setting.
  18. 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.
  19. Patient or staff death or serious injury associated with a burn from any source in the course of a patient care process in a healthcare setting.
  20. Patient death or serious injury associated with a fall suffered in the hospital, nursing home, or other healthcare setting.
  21. Patient death or serious injury associated with the use of restraints or bedrails.
  22. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist or other licensed healthcare provider.
  23. Abduction of a patient or resident of any age.
  24. Sexual abuse or assault on a patient or staff member within or on the grounds of a healthcare setting.
  25. Death or significant injury of a patient or staff member resulting from a physical assault within or on the grounds of a healthcare setting.
  26. Artificial insemination with the wrong donor sperm or donor egg.
  27. Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen.
  28. Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology or radiology test results.
  29. Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area, including incidents where the patient contains the metallic object, such as an implanted pacemaker.

In addition, the Department of Public Health has added certain reportable "Connecticut-specific events." These include:

  1. Perforations during open, laparoscopic and/or endoscopic procedures resulting in death or serious injury.
  2. Patient death or serious injury as a result of surgery, including hemorrhage or loss of more than 30% of the circulating blood volume.

The NQF and DPH have decided to "retire" the following adverse events from this list, although those events could still give rise to death or serious injury and be legally actionable:

  1. Patient death or serious injury associated with the onset of hypoglycemia, a drop in blood sugar, while being cared for in a health care facility.
  2. Death or serious injury associated with failure to identify and treat hyperbilirubinemia, a blood abnormality, in newborns.
  3. Patient death or serious injury due to spinal manipulative therapy.

The "never event" list is published by NQF, a partnership of about 375 governmental and private organizations involved in providing and paying for health care for Americans, including large corporations, insurers, medical specialty organizations, hospitals, drug companies, unions, charities, and government agencies. Its Connecticut members include Connecticut Hospital Association, St. Francis Hospital and Medical Center, and Yale New Haven Health System. It is dedicated to improving the quality of health care in the United States.

Not every "never event" gives rise to a meritorious malpractice case. Each case must be evaluated on its merits for liability, causation and damages. We are committed to making fair and timely evaluations of potential malpractice cases at no cost to the client.

For further information about NQF, visit www.qualityforum.org