What to Do in the Event of a Never Event

Much has been written about how to prevent such never events as wrong-site surgery and retained objects, but how are you supposed to respond should one occur at your facility?

The Leapfrog Group, a national advocacy group dedicated to improving healthcare safety, developed a best practice for responding to serious and avoidable never events, which includes the following recommendations:

  • Apologize to patients and their families, to rebuild trust and lessen the likelihood of being sued.
  • Report the event to an outside agency, such as the Joint Commission or National Quality Forum, within 10 days to promote the uniform and public reporting that's needed to improve universal safety efforts.
  • Perform a root cause analysis to determine why the error occurred and how it could be prevented in the future.
  • Waive the costs of care related to the event for the patient and insurer.
  • Make your facility's policy on responding to never events available to patients and insurers to ensure transparency in error reporting.

In its annual survey of U.S. hospitals, Leapfrog asks if facilities use this best practice response when things go seriously wrong. In 2007, the first year Leapfrog asked the question, 53% of hospitals reported having implemented its recommended response protocol. Last year, 80% of hospitals said they followed the protocol. Every reporting hospital in Maine, Massachusetts and Washington met the standard, but only 10% of Arizona's hospitals were compliant.

Leapfrog says the percentage of hospitals with protocols in place has plateaued at 80% since 2012, meaning 1 in 5 facilities fall short of the optimal response to never events. The organization says more reporting transparency is needed to create national benchmarks of safety that ultimately lead to improved policies that protect patients from harm.

Daniel Cook

Two Simple Steps Can Prevent Post-op Delirium

Two relatively simple steps can help you reduce the risk of post-op cognitive dysfunction among your older surgical patients, according to a recent study.

Brazilian researchers found that patients who are given a small dose of the anti-inflammatory dexamethasone pre-operatively and who aren't put under deep anesthesia during surgery are less likely to suffer from the temporary or permanent loss of memory and concentration that may follow surgery.

In the study, researchers evaluated 140 patients aged 60 to 87 years who received surgery with propofol-induced anesthesia. The researchers pre-operatively assessed the patients' mental and cognitive status, then grouped them into 4 categories. The first and third group received deep anesthesia while the second and fourth group received more superficial anesthesia. The third and fourth groups also received dexamethasone before their surgeries.

Only 15.3% of patients in the group that received superficial anesthesia and pre-op dexamethasone showed post-op cognitive dysfunction immediately after surgery, and all returned to their pre-op cognitive status after 6 months. Patients in the other 3 groups didn't fare as well, say researchers.

"The results reinforce recent evidence of the importance of avoiding deep anesthesia," says Maria José Carvalho Carmona, a professor of anesthesiology at the University of Sao Paulo's Medical School and lead author of the study. "With regard to the use of dexamethasone, more research is needed to confirm our finding, preferably in multicenter trials, but there are strong indications that it can be beneficial in many cases."

Kendal Gapinski

Outpatient Nephrectomy?

Add another procedure to the list of those that can be done safely and effectively in outpatient settings. Researchers in Denmark have found that carefully selected patients who undergo laparoscopic nephrectomy needn't be hospitalized.

The study, which was published in the Journal of Urology involved 50 patients with a mean age of 59.8 years. Of those, 46 were discharged within 6 hours of surgery, and none of the 46 were readmitted within 30 days. Two developed infections, but both were successfully treated with oral antibiotics. The 4 patients who weren't discharged were admitted because of medication errors (2), fatigue and intestinal injury (1 each).

To be eligible, patients had to:

  • be between age 30 and 70,
  • be able to read and write,
  • have non-metastatic kidney cancer,
  • not have cardiac disease that would require intensive care or postoperative monitoring; and
  • have relatives at home for the first 24 hours after discharge.

"Our study demonstrates that outpatient nephrectomy may be done safely and does not require hospital readmission," say the authors, adding that more than 40% of candidates are likely to meet inclusion criteria.

Jim Burger

InstaPoll: When Can Anesthesiologists Go Home?

  • Supreme Court rejects surgical standards for abortion in Texas A Texas law that held abortion clinics to the same standards as ambulatory surgical centers and required the physicians operating there to maintain hospital admitting privileges was struck down by the U.S. Supreme Court in a 5 to 3 decision on Monday.
  • Who makes the most wrong-site errors? Of the 689 wrong-site events reported to and analyzed by the Pennsylvania Patient Safety Authority between July 2004 and March 2016, more than one-fourth (26.6%) were anesthetic blocks injected into the wrong place. Wrong-level spinal procedures followed at 12.8%, and off-target pain management procedures rounded out the top half of all errors at 11.5%.
  • Pathogenic pitfalls of portable phones While 64% of healthcare workers use mobile or cordless phones during the delivery of patient care, 20% of them admit they don't sanitize their hands before or after handling the devices, say French researchers. Since the team also determined that the portable electronics can carry epidemic viruses as well as nosocomial bacteria, they emphasize the importance of enforcing hand hygiene and device disinfection protocols.
  • When alerts are the safety hazard While the widespread implementation of electronic health record systems was intended to avert medical errors, the automated, repetitive and sometimes irrelevantly cautious alerts with which they routinely overwhelm physicians, nurses and pharmacists have created a patient safety hazard of their own, according to a recent Washington Post article on "alert fatigue." The article notes that EHR users ignore safety notifications between 49% and 96% of the time.