By Nursing Home Law Center
California enacted a state law in July 2007 requiring hospitals to report “never events” (events that are never supposed to be allowed to happen). Never events include severe bedsores (stage 3 or 4), foreign objects left inside surgical patients, surgery performed on the wrong body part, surgery performed on the wrong patient, air embolism, blood incompatibility, and CATIs (catheter-associated urinary tract infections).
Hospitals are required to report these “never events” to the California Department of Public Health. If a hospital fails to report these events they face $100 fine for each day the event goes unreported. State officials hoped that the law would help hospitals identify and address problem areas to improve patient treatment. Unlike hospitals, long-term care facilities and nursing homes are not required to report never events.
Other states, such as Illinois, have similar reporting programs with, such as the Illinois Hospital Report Card and Consumer Guide to Health Care. This program also only requires hospitals to report medical errors, infections, and other issues. Improved reporting systems will help educate medical professionals about common mistakes in their own hospitals.
An American Medical News article states that hospital error-reporting systems are falling short. This is because many hospital reporting systems do not allow doctors, nurses, and other hospital staff members report mistakes anonymously. This means that many errors and problems go unreported, which does nothing to help reduce errors and improve patient safety.
Between 2007 and 2009, 106 facilities were fined almost $1 million for failure to report or delays in reporting never events. This list included four Riverside County hospitals (Parkview Community Hospital Medical Center in Riverside, Kaiser Permanente’s Riverside Medical Center, Riverside Community Hospital, and Desert Regional Medical Center in Palm Springs) for delays in reporting never events. Most of these events were severe bed sores.
Bed sores (otherwise known as pressure sores, pressure ulcers, or decubitus ulcers) are a common but preventable problem. (See “Is It True That Bed Sores Are Preventable?”) If left untreated, pressure sores can grow and become infected, requiring drastic and painful treatment.
Prevention is key because decubitus ulcers are easier to prevent than to treat, and it avoid putting the patient in unnecessary pain and discomfort in addition to being put at risk for serious health complications such as sepsis and even death. Bed sores can be prevented by conducting daily skin inspections (especially for at risk patients), using pressure reducing mattresses, pressure-release wheelchairs, frequent position changes, minimizing friction, and healthy diet.
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