Avoidable Medical Errors, Such as Decubitus Ulcers, Continue to Rise in Hospitals Despite Reduction Methods

By Nursing Home Law Center

The term “never event” earned its name simply due to the fact the government determined that that the events should never happen in properly functioning hospitals. As an added incentive for hospitals to prevent these situations from occurring, the government will not reimburse hospitals for these medical errors. These events include:

• Leaving foreign objects inside surgical patients;
• Surgical site infections;
• Air embolisms;
• transfusionsUsing the wrong blood type;
• Inadequate glycemic control;
• Severe Pressure sores; (See “Simple Preventative Techniques Can Drastically Reduce The Rate of Hospital-Acquired Decubitus Ulcers”);
• Post operative pneumonia;
• MRSA infection (methicillin-resistant Staphylococcus aureus);
• Falls and trauma; and
• Catheter-associated urinary tract infections (UTIs).

All too many of us, especially those of us with family members in nursing home facilities, know someone who has suffered from one of these “never events.” In the month of July, medication-error deaths are 10% higher than any other month because medical school graduates are just beginning their residencies. Apparently, the most common foreign object left inside a surgical patient is a surgical sponge.

In 2008, the Centers on Medicare and Medicaid decided to stop reimbursing hospitals for these “never events.” This is so hospitals are not paid for the procedure that caused the never event and the follow-up treatment to treat the error.

In California, 14% of preventable errors over the last two years were caused by “retained foreign objects.” In response, the state plans to use some of the money collected from hospital fines to research how to reduce these preventable hospital mistakes.

Illinois is taking steps to reduce hospitals errors with its website, the Illinois Hospital Report Card and Consumer Guide to Health Care. This site provides hospital information to consumers and includes a report card including staffing, infection prevention, and quality care.

However, “never events” are not always preventable. Some patients, because of poor condition (malnutrition, kidney failure, etc) prior to surgery, are more likely to suffer from certain surgical complications, including “never events.” For example, patients requiring colon resection are more at risk for post-surgical infections and pressure ulcers. This might deter physicians from working with patients with certain risk factors because if something goes wrong and a never event occurs, the hospital might not get paid by Medicare or insurers who adopted similar payment policies.

In addition, no matter how many new policies and improvements are put in place, humans practice medicine and human-error can still occur. Hopefully, additional oversight and transparency will help reduce dangerous and preventable hospital errors.

Related Information

• SF Gate: Avoidable Mistakes Rise Despite Hospital Efforts
• Medical News Today: In Hospital Deaths from Medical Errors at 195,000 per Year USA
• The Washington Post: Hospitals Tally Their Avoidable Mistakes
• Illinois Hospital Report Card and Consumer Guide to Health Care
• New York Times: Who Pays for Medical Complications?
• California Case Values
• Illinois Case Values

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