PANEL SESSION: NEVER EVENTS- HOW TO MAKE SURE THEY NEVER HAPPEN


AVAS Moderator Panel discussion Houston 2017


At the 2016 AVAS Annual Meeting (Virginia Beach VA), L.D. Britt, MD MPH (Chair Department Surgery EVMS, Past President ACS, and Commissioner of the Joint Commission) welcomed the group to Hampton Roads. During his address, Dr. Britt expressed his concerns that, despite many protocols and precautionary measures across the US, little, if any, progress had been made in eliminating “Never Events”. At the conclusion of his remarks, Dr. Britt proposed a challenge to VA surgeons to develop processes that could be utilized outside the VA to address never events. Following his challenge, Dr. Britt explained his perspective on this topic (see interview published at http://bulletin.facs.org/2017/02/how-do-we-improve-patient-safety-a-look-at-the-issues-and-an-interview-with-dr-britt/). The controversy surrounding never events was evident at the August 2016 National Surgical Patient Safety Summit (NSPSS) program sponsored by the American College of Surgeons and the American Academy of Orthopedic Surgeons (attended by Gordon Telford MD and Kenneth Lipshy MD). Based on these events, the AVAS 2017 annual meeting program committee determined that a panel discussion on “NEVER EVENTS- HOW TO MAKE SURE THEY NEVER HAPPEN” would be appropriate.


L.D. Britt, MD reviewed the “HISTORY AND DEFINITION, DEMOGRAPHICS, CURRENT PRACTICE OF PREVENTION.” During which he expressed several concerns. His initial point was that in spite of the US spending 18% of its gross domestic product on health care, the US ranks 68th (below Ghana) in health and well-being, and below most industrialized nations in terms of quality of care, access, equity, and life expectancy. He next discussed the fact that "never events" such as retained surgical items and wrong procedure/wrong site surgery occur 40 times per week. In 2014, retained surgical items were more common than other sentinel events including falls, suicide, delays, and medication errors. Dr Britt pointed out that the multiple steps leading to a surgical procedure certainly increase the risk of an adverse event. He has challenged surgeons to take the lead in assessing the quality of these steps and to establish checkpoints along the way to assure the accuracy of information that could potentially lead to an error.


Robin R. Hemphill, M.D., M.P.H. (Deputy Chief Patient Safety Officer Director, VA National Center for Patient Safety Ann Arbor, MI) next discussed “LESSONS LEARNED FROM THE NATIONAL CENTER FOR PATIENT SAFETY”. Dr Hemphill noted that in a 2011 VA study (Arch surgery 146(11):1235-1239), the rate of reported adverse events decreased from 3.21 to 2.4 per month. During the same reporting period, close calls increased from 1.97 to 3.24 per month. The NCPS is focusing on educating health care staff of the importance in relaying near-misses so lessons can be learned. The NCPS is focusing on changing the culture of safety in the VA by addressing hierarchal relationships, emphasizing human factors, promoting standardization, leadership engagement, and encouraging participation in reporting/analysis of critical incidents. Starting in 2010, the NCPS began sharing their lessons learned with the VISN Chief Surgical Consultants. These lessons are then shared during subsequent VISN Surgical Workgroup calls.


Rani Elwy, Ph.D (Director, Health Communications Research Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston, MA) next discussed her group’s experience in “SURGEONS’ DISCLOSURES OF CLINICAL ADVERSE EVENTS.” Her group performed a study during which they interviewed surgeons, patients and families involved in adverse events. Further details can be found in another article in this newsletter.


Ruth L. Bush, MD, JD, MPH (Deputy Director (IQuESt) Center for Innovations In Quality, Effectiveness, and Safety; Professor Surgery BCM Houston, TX) concluded the panel session with a talk entitled “NEVER SAY NEVER: THE MEDICAL LEGAL IMPACT OF NEVER EVENTS.” She first clarified that never events are classified as such because the events are related to substantial risk to the patient and devastating outcomes, including death. She next discussed the disclosure process and how this should occur as soon as possible, focus on the effect upon the patient, be documented in the medical record, and include key facility leadership and inform patients of their legal rights. She explained that patients want an apology, an explanation of the events which transpired, and to know which actions to prevent future occurrences have been taken. She concluded the session by comparing the federal (VA) and civilian tort processes highlighting that while monetary damages are paid by the government, all substantiated claims are reported to the National Practitioner Data Bank.




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