by Sean Power

What are Never Events?

Never Events are 28 preventable actions or mistakes that should never happen in a health care setting, which include:

• Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
• Intraoperative or immediately post-operative death in an ASA Class I patient (which includes a normal healthy patient)
• Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended

Wikipedia maintains a list all 28 Never Events.

The National Quality Forum in the United States initially compiled the list. Never Events are quite rare, although the consequences of Never Events can be devastating. How often do Never Events happen?

Some states such as Minnesota have mandatory public reporting laws. Many hospitals are not mandated by their states to report Never Events, though, making it difficult to collect precise numbers. According to The Leapfrog Group, Minnesota has averaged around 100 reported Never Events per year.

Researchers from John Hopkins University School of Medicine in Baltimore conducted the first study to calculate a national rate for Never Events, identifying a total of 9,744 paid malpractice settlement and judgment claims for surgical Never Events between 1990 and 2010.

What is being done to prevent Never Events at health care facilities?

The Centers for Medicare and Medicaid Services (CMS) announced in 2007 that Medicare would no longer pay for additional costs associated with Never Events.

In addition, many hospitals voluntarily publicly report Never Events to increase accountability.

According to Lippincott’s Nursing Center, hospitals that successfully prevent Never Events have established cultures of safety. In other words, hospitals act in the safest manner possible regardless of the degree of regulatory supervision—both management and frontline staff adopt high-reliability behavior such as preoccupation with failure, reluctance to simplify interpretation, and deference to expertise, among other acts.

Which Never Events are associated with Patient-Controlled Analgesia Pumps?

Patient-Controlled Analgesia (PCA) pumps were developed to address under-medication problems for patients requiring pain management. PCA pumps permit the patient to self-administer small doses of narcotics after surgery as a method of pain control.

The risk of respiratory depression can be too great for “opioid naïve” patients—patients who have never experienced prior opioid use—and PCA pumps are now only used for patients who have previously used opioids. Despite these (and other) preventative measures, respiratory depression still occurs too frequently, resulting in serious adverse events and negative patient outcomes.

Of the Never Events listed by the National Quality Forum, PCA pumps might be at risk of contributing to patient death or serious disability associated with a medication error (e.g. incorrectly programming the pump) and with the use or function of a device in patient care in which the device is used or functions other than intended (e.g. a patient’s relative administers medication through the PCA pump on behalf of the patient).

Should dead-in-bed syndrome while on PCA pumps be added to the list of Never Events?

Never Events have two common characteristics: they are totally preventable and they result in serious adverse events. Patient deaths caused by respiratory depression while using PCA pumps share these traits. Therefore, dead-in-bed syndrome needs to be added to the list of Never Events.

Experts would agree. In another article on dead in bed syndrome, Dr. Andrew Kofke, Co-Director at the Hospital of the University of Pennsylvania Neurocritical Care Program, says, “we should stop the found dead in bed syndrome. The use of a well-constructed checklist that ensures proper procedures are followed in patient-controlled analgesia would enhance patient safety.”

The PPAHS has also advocated elsewhere on this website that healthcare facilities adopt a PCA safety checklist. Doing so will minimize the likelihood for adverse events to occur.

With continuous end tidal CO2 monitoring of the adequacy of ventilation with capnography and pulse oximetry for oxygenation, nurses are alerted and can intervene before respiratory depression causes serious adverse events. Dead-in-bed syndrome is thus totally preventable and shares the first characteristic of the Never Events list.

Dead-in-bed syndrome can also have devastating or drastic effects, thus sharing the second common trait with the Never Events list. By failing to monitor patients with capnography and pulse oximetry, patients like Amanda Abbiehl and Leah Coufal would not have been found unresponsive and dead-in-bed. These stories prove that respiratory depression can cause serious adverse events with negative patient outcomes, therefore sharing the second characteristic of the Never Events list.

It necessarily follows that dead-in-bed syndrome while on PCA pumps should be added to the list of Never Events, for they share the two key traits that are common to all other Never Events.

Where can I go to learn more about Never Events?

The PPAHS has compiled the following list of resources about Never Events:

AHRQ Patient Safety Network – Never Events

The Agency for Healthcare Research and Quality published a backgrounder on Never Events. People looking for an introduction to the topic will find this AHRQ article helpful.

Preventing Never Events: What Frontline Nurses Need to Know

Lippincott’s Nursing Center explains Never Events and their consequences. The article targets an audience with a nursing background; however, anybody working in the space can benefit from the frontline perspective.

Surgical never events in the United States

The journal Surgery published an article that examines the frequency of Never Events, their costs to the health care system, the outcomes of patients, and the characteristics of providers involved in adverse events. The results of the study may help health care providers create prevention strategies for patients post-op.

What do you think? Should dead in bed syndrome be added to the list of Never Events? Leave your comments below.

• Opioid Safety
• Respiratory Compromise