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Shocking and Unexpected Medical Errors

Shocking and Unexpected Medical Errors

Shocking and Unexpected Medical Errors
Never events can occur with: surgical events, product/device events, patient protection events, and care management events (Austin & Pronovost, 2015).
What are “never events”? How are these reported? Include appropriate regulatory agencies that are responsible for the prevention of harm to patients in the healthcare environment.

Professor Sherman

Austin, J. M., & Pronovost, P. J. (2015). “Never events” and the quest to reduce preventable harm. Joint Commission journal on quality and patient safety, 41(6), 279-288.

Shocking and Unexpected Medical Errors

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In the medical field, never events refer to various shocking and unexpected medical errors like performing surgery on a patient at the wrong site. These are errors that should never happen. Over some time, this term has been used extensively to refer to severe events that are measurable and easily identifiable, but that can always lead to injuries like disability or death. These events are, however, usually preventable (Tingle, 2018). The initial never list event was developed in the year 2002. Since then, the list has been severally revised and now consists of 29 severe and reportable events organized into a group of seven.
Human beings are bound to making errors, and never events are part of these errors. Therefore, the institute of medicine recommended the development of a countrywide, compulsory, state-based system of reporting to help understand the frequency of such severe events that could lead to severe harm or even death. In response to this recommendation, the National Quality Forum presented a report of Serous Reportable Events in Healthcare that identified and authenticated the list of 27 avoidable occurrences to help in reporting (Sanghavi et al. 2020). Alternatively, the data on never events can be obtained via several methods that include the hospital doing a self-reporting of the event to the Patient Safety Organization or a government-related agency. Health records from routine screening and 19 reviews of patient data claim that are often submitted by hospitals.
The National Quality Forum agency does not intend to deal with all the never events that might cause harm but rather, to establish a common consensus understanding across the health care stakeholder associations about a composition list of avoidable severe adverse occurrences that should never happen and to help in the reporting of such events (Sanghavi et al. 2020).

Sanghavi, P., Pan, S., & Caudry, D. (2020). Assessment of nursing home reporting of significant injury falls for quality measurement on nursing home compare. Health Services Research, 55(2), 201-210.
Tingle, J. (2018). Never events in the NHS. British Journal of Nursing, 27(3), 166-167.

Shocking and Unexpected Medical Errors

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