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“Never Events”: Will They (N)Ever Go Away?
Maryland Association for Healthcare Quality
October 29, 2009
Health Science Institute
Larry L. SmithVice President, Risk Management, MedStar Health, Inc.
President, MD-DC Society for Healthcare Risk Management
MHA’s Payment Guidelines on Serious Adverse Events
Maryland Hospitals agreed that whenever one of these events result in death or serious disability to a patient the hospital would waive payment for any of the stay:
– Surgery on wrong body part– Surgery on wrong patient– Wrong surgical procedure– Unintended retention of a foreign object– An air embolism that occurs while being treated – A medication error resulting in death, paralysis, coma
or other major permanent loss of function.– A hemolytic transfusion reaction due to administration
of incompatible blood or blood products
MHA’s Payment Guidelines on Serious Adverse Events
In addition, Maryland Hospitals agreed to evaluate on a case-by-case basis whether full or partial payment should be waived for other event that resulted in patient death or serious disability based on:
• Was the error or event preventable?• Was the error or event within the control of the
hospital?• Was the injury to the patient the result of a
mistake made in the hospital?
MedStar’s Adverse Event Reporting SystemWhat is reported
• Serious Safety Harm Report– Any event resulting in death or serious harm– Surgery on wrong body part– Surgery on wrong patient– Wrong surgical procedure– Unintended retention of a foreign object– An air embolism that occurs while being treated – A medication error resulting in death, paralysis,
coma or other major permanent loss of function.– A hemolytic transfusion reaction due to
administration of incompatible blood or blood products
Source: Duke University Medical Center Patient Safety – Quality ImprovementSource: Duke University Medical Center Patient Safety – Quality Improvement
Source: Duke University Medical Center Patient Safety – Quality ImprovementSource: Duke University Medical Center Patient Safety – Quality Improvement
Preventable Errors I Have KnownWrong: • Limb• Side of head (neurosurgery)• Level spine surgery• Patient (cath’ed)• Procedure-right patient
(bunioinectomy v. foot release)• Blood Type• Patient Circumcised• Test results given to patient (AIDS)• Solution used to clean site (100%
acetic acid)• Drug:
– dose – Administration-route
• Organ(s) transplanted• Organ removed
Retained:• Sponge• Kelly Clamp• Needle• Retractor (14” by 3”)• Tip of glove
How should we respond when a patient is injured due to error?
• Disclosure – What? When? Why? Who?
• Apology or Expression of Regret?
• To Bill or not to Bill?
• Discipline or Blamelessness?
Disclosure• Why?
– Right thing to do– Reinforces for staff that transparency is a core value
of the organization and its leadership– Risk management issues are secondary, not
primary……... “the patient may not sue”
• What?– The facts as we know them to be
• When?– As soon as the patient/family is psychologically and
physically ready
Disclosure
• Who:– Requires a situational analysis – often best
done by – or at least in the presence of -someone with a pre-existing relationship with the patient/family
Apology or Expression of Regret?
• Expressions of regret are appropriate for all unanticipated outcomes
• Apology is appropriate when the unanticipated outcome was clearly caused by unambiguous error or system failure