Recently, Health Quality Ontario and the Canadian Patient Safety Institute released “Never Events” for Hospital Care in Canada, a report that represents the first national consensus document on a list of events that health care institutions must work to eliminate. The document includes a list of 15 “never events” and guidance on how institutions can prevent such occurrences and shift the culture to become more open and willing to report mistakes and problems. Never events are patient safety incidents that result in serious patient harm or death, and that can be prevented by using organizational checks and balances. Fortunately, many of these events occur only rarely, but all can have a severe impact on the lives and well-being of patients.
The Never Events Action Team presents the following list of 15 never events for hospital care in Canada.
- Surgery on the wrong body part or the wrong patient, or conducting the wrong procedure.
- Wrong tissue, biological implant or blood product given to a patient
- Unintended foreign object left in a patient following a procedure
- Patient death or serious harm arising from the use of improperly sterilized instruments or equipment provided by the health care facility
- Patient death or serious harm due to a failure to inquire whether a patient has a known allergy to medication, or due to administration of a medication where a patient’s allergy had been identified
- Patient death or serious harm due to the administration of the wrong inhalation or insufflation gas
- Patient death or serious harm as a result of one of five pharmaceutical events.
a. Wrong-route administration of chemotherapy agents, such as vincristine administered intrathecally (injected into the spinal canal)
b. Intravenous administration of a concentrated potassium solution
c.Inadvertent injection of epinephrine intended for topical use
d. Overdose of hydromorphone by administration of a higher-concentration solution than intended
e. Neuromuscular blockade without sedation, airway control and ventilation capability
- Patient death or serious harm as a result of failure to identify and treat metabolic disturbances (e.g. hypoglycaemia).
- Any stage III or stage IV pressure ulcer acquired after admission to hospital
- Patient death or serious harm due to uncontrolled movement of a ferromagnetic object in an MRI area
- Patient death or serious harm due to an accidental burn
- Patient under the highest level of observation leaves a secured facility or ward without the knowledge of staff
- Patient suicide, or attempted suicide that resulted in serious harm, in instances where suicide-prevention protocols were to be applied to patients under the highest level of observation
- Infant abducted, or discharged to the wrong person P
- Patient death or serious harm as a result of transport of a frail patient, or patient with dementia, where protocols were not followed to ensure the patient was left in a safe environment
In addition, from year 2008. US Medicare is no longer paying the extra cost of treating the following categories of conditions that occur while the patient is in the hospital.
- pressure ulcer stages III and IV
- falls and trauma
- surgical site infection after bariatric surgery for obesity, certain orthopedic procedures, and bypass surgery (mediastinitis);
- vascular-catheter associated infection;
- catheter-associated urinary tract infection; administration of incompatible blood;
- air embolism; and
- foreign object unintentionally retained after surgery.
Obviously there is a significant overlap between American and Canadian “never events” although the lists are by no means exhaustive. Instead of accepting the pro-active approach in fighting medical errors US physicians are responding by practicing defensive medicine. A Jackson Healthcare survey uncovered that the vast majority of doctors, 92 percent, made medical decisions according to legal concerns rather than providing the best standard of diagnostic care for their patients.
Every year, patients endure hundred of thousands of unnecessary tests and procedures, ordered to avoid any potential of medical malpractice. Eight percent of all surgeries, 14 percent of prescriptions and more than a quarter of all tests are performed to avoid litigation. The resulting cost to the American health care system alone measures between $650-$850 billion per year. Even worse, some doctors actively avoid treating patients listed as “high-risk cases” for lawsuits.
While there are many effective “In-Hospital” strategies, is there an effective remedy to fix this huge problem in Hospitals worldwide. What are the options? Fundamentally healthcare and Hospital Accreditation is about improving how care is delivered to patients and the quality of the care they receive.
Accreditation is one important component in patient safety. Accreditation has been defined as “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve”.
Several recent meta-analysis confirmed the unequivocal positive impact of International Hospital Accreditation on the Quality of Healthcare Services in Hospitals world-wide.
There is considerable evidence to show that accreditation programs improve clinical outcomes of a wide spectrum of clinical conditions. Accreditation programs should be supported as a tool to improve the quality of healthcare services.
So go for it!
Sources:
http://www.hqontario.ca/Portals/0/documents/about/report-never-events-hospital-care-en.pdf
https://downloads.cms.gov/cmsgov/archiveddownloads/SMDL/downloads/smd073108.pdf
http://www.jacksonhealthcare.com/media-room/surveys/defensive-medicine-study-2010.aspx
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3156520/