Ken Kizer, a physician and former chief operating officer of the National Quality Forum, coined the term “Never Events”. These are particularly shocking medical errors, like operating on the wrong patient, that should never happen. The NQF defined 27 such events in 2002 and revised and expanded the list in 2006. The list is grouped into six categorical events: surgical, product or device, patient protection, care management, environmental, and criminal. They are also referred to as serious reportable events. Some or all of these events are reportable to state agencies. Organizations accredited by The Joint Commission are expected to report these events to The Joint Commission.
See the list: SRE_FactSheetv2
Beginning October 2008, the Centers for Medicare and Medicaid Services stopped reimbursing hospitals for care that resulted in one of a limited list of never events. Private payors followed suit. The healthcare facility is not permitted to bill the patient for the revenue that was lost as a result of this never event.
Why do these events continue to happen? Health care is incredibly complex and there are multiple opportunities for errors – related to communication, the environment, fatigue, stress, and a host of other factors. Healthcare providers don’t want set out to hurt people – this blog explores some of the reasons why that happens and how that influences the litigation process.