Never Events

The blogger community is abuzz with the latest list of pronouncements of 'never events'. Never events are unintentional injuries or complications that occur while people are under care (usually in a hospital) that are preventable. Something like operating on the wrong body part or a medication error.

What is causing the uproar is that Medicare has a) refused to pay for the management of the 'never event' if it was caused in the hospital b) expanded the list to include complications that can be difficult/impossible prevent.

I'll give an example. While a resident, we placed a tracheotomy for a patient who developed throat cancer. One Sunday after noon, frustrated at his ability to eat and suicidal, he decided to cut his tracheotomy out; almost bleeding to death. Under the guidelines, the event was preventable and management of it should not have been paid (surgery, transfusions, etc...)

Dr. Val, once again, has given an eloquent review of the situation and it's unintended consequences from the U.S. perspective. But Ontario, Canada is now starting to track the rate of 'never event' complications and in an ominous prelude to what I suspect is coming for Ontario Hospitals they report:

"People with chronic disease who are not properly cared for can have their health break down,
which, in addition to their suffering, is expensive for the health-care system."

If it were as simple as operating on the wrong person few would take issue. The problem, is that funding is being tied to events that would never stand the test of a court of law in proving that the hospital caused them. Infections that are frequent but proven preventable, patient suicide in hospital, immediate post-operative death of a healthy patient, death or serious disability from a medication error. On top of that, there is a good argument that the total cost to the system is increased by unrealistic expectations.

The problem is that some of the events are rare but difficult to foresee or prevent. Other event, occur so frequently in hopsital that preventing errors is occasional errors is nearly impossible. In the case of medication errors, even if a hospital achieves six sigma status (3.4 errors per million events) they would still be loose funding.

So far, the Ontario government is looking to track and presumably prevent adverse complications in hospital. I am all for driving 'never events' into 6-sigma levels (or higher) but let's hope that we achieve the goal through great management.