Archive for June 30th, 2010

Posted on June 30, 2010 - by Nurse Virginia

NEVER EVENT – WHY JUST FOR HEALTHCARE?

“Never Events” refer to a list of 28 inexcusable outcomes, the result of spending some time in a healthcare setting. Of course the most horrendous of the hospital events are on the list. As horrific and newsworthy as these events are:

• A foreign object left in a patient after surgery
• Giving a patient the wrong blood
• Surgery on the wrong body part
• Surgery on the wrong patient
• A patient death due to medication error
• Patient death due to electric shock in the healthcare facility
• Patient death due to a fall in the healthcare facility
• Patient death due to a burn sustained in the healthcare facility

These are considered, and rightly so, events that should never happen in a healthcare setting. Medicare started denying payment for eight never events in October of 2009. Insurance companies usually follow Medicare’s lead and of course we can expect everyone to really run with this. At some point, that original list will really seem like small potatoes. Of course as money is saved refusing payment, I doubt the patients will see any savings.

However, when we get into the area of skin breakdown in the elderly, can we be as sure as to where to place blame?  (In-house acquired wounds and infections are on the list) Or, how about infections acquired in a healthcare setting?

I remember an elderly lady who in her last month of life did start to have “in-house acquired” skin breakdown. She had large, very dark areas of skin, that you just knew were going to open up and be ugly. Because the breakdown was happening from the inside out – not from the outside in, (as happens with poor care) we realized this was just part of her body shutting down.  As this wonderful woman was dying the Director of Nursing wanted her sent out of the building, because she didn’t want one of those “in-house” acquired wounds in her building. Fortunately, common sense prevailed and this elderly woman was allowed to stay, and die being cared for by the staff that had gotten to know her so well for her last six years.

Blame is easy to assign, when a blatant mistake is made. But, sometimes it’s not so easy to designate the blame, and playing the blame game, can take the focus away from patient care.

Here’s an idea. How about coming up with a list of “Never Events” for the Oil Industry?  Maybe some “Never Events” for Congress that makes them stop and think before they allow Wall Street to bet against the country? How about some “Never Events” to prevent the real estate industry from falsifying applications so people can buy what they can’t afford? Just a thought.

Virginia Garberding, R.N.

Director of Education, The Wealshire, Lincolnshire, Illinois

Author: Please Get To Know Me – Aging with Dignity and Relevance

www.pleasegettoknowme.com