When a “Never Event” Occurs at a Hospital, It Frequently Goes Unreported

Hospitals often refer to tragedies that should not happen in a medical setting as “never events.” These may include patients dying during routine procedures or major medication errors. Saying that they should not happen does not mean that they do not, unfortunately, and few resources are available to track just how frequently “never events” occur.

Any effort to track this type of event is dependent upon reporting by hospitals and other medical providers, who often have both legal and business reasons to prefer not reporting. Hospitals may wish to keep such information private for fear that it could be used against them in litigation. While this may not be an unreasonable worry, it does nothing to alleviate concerns about public safety. Furthermore, any such information that directly pertains to a claim for medical malpractice should be relevant information available through discovery. It turns out that the discovery process may remain the main method for medical malpractice attorneys to obtain information on specific errors.

Hospitals may also cite fear of losing business as a reason to keep “never event” information private, as people would take their business elsewhere, or they might avoid care entirely. The argument that a patient might forgo care rather than risk seems reasonable to an extent, but the interest in having accurate information seems greater.

Finally, patient privacy laws may prevent reporting of specific information on errors. Privacy protections are available, through which hospitals can submit reports with redacted patient information.

Congress passed the Patient Safety and Quality Improvement Act of 2005 (PSQIA) in order to address some of these concerns, but the law does not directly address the issue of public availability of information. The law encourages hospitals to report dangerous conditions, adverse events, and near misses to a system of patient safety organizations (PSO), also created by this law. It also provides for confidentiality of what it defines as “Patient Safety Work Product.” The definition of Patient Safety Work Product is quite broad, encompassing almost all features of an error report, and disclosure is only permitted in strictly-defined circumstances. These circumstances do not seem to include litigation, except after an extensive process of “nonidentification.” The PSQIA also created a national database that allows information to be shared among the PSO’s, obviously subject to the strict disclosure requirements. However, the PSQIA does not require hospitals to report adverse events to the nearest PSO. All reporting under this law is strictly voluntary

Maryland created its own organization to review such data, the Maryland Patient Safety Center (MPSC), in 2004. It has been listed as a federally-approved PSO since 2008. While the MPSC touts its efforts to bring medical providers together to review the causes of dangerous practices and develop and implement solutions, it does not appear to offer readily available information to the public either. It offers a voluntary “regional patient safety adverse event and near miss reporting system” for Maryland healthcare providers.

The Maryland injury lawyers at Lebowitz & Mzhen represent the rights of people who have suffered injury from malpractice by medical professionals. To schedule a free and confidential consultation, contact us online or at (800) 654-1949.

Web Resources:

The Patient Safety and Quality Improvement Act of 2005, Agency for Healthcare Research and Quality
Maryland Patient Safety Center home page

More Blog Posts:

“Good Catch” Program Hopes to Encourage the Reporting of Pharmacy Errors Before They Occur, Pharmacy Error Injury Lawyer Blog, September 20, 2011
Hospital Patients are Subject to an Average of One Medication Error per Day, Pharmacy Error Injury Lawyer Blog, September 14, 2011
$2.5M Maryland Medical Malpractice Verdict to Family of Man Who Died After Suffering Hemorrhagic Shock Following Doctor’s Failure to Diagnose, Maryland Accident Law Blog, August 23, 2011
Photo credit: taliesin from morguefile.com

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