What Really Causes ‘Never Events’ to Occur?

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NEV-thumb2A topic that comes up occasionally in HCE’s interviews with healthcare executives is the subject of patient falls, especially in the overall context of patient safety. In fact, John Ryan of NPR reports that falls are actually playing into a larger conflict “between nurses and hospitals over how to improve the safety of hospitalized patients.”

Ryan offers up Gene White as an example. He was hospitalized overnight in Seattle’s Swedish Medical Center to take care of some back pain. He was having trouble sleeping and was given Ambien by a nurse.

“The Mayo Clinic in Minnesota has found that hospital patients who have taken Ambien are four times more likely to suffer a fall,” Ryan points out.

Sure enough, White began sleepwalking, fell, broke three ribs, and ended up being hospitalized for two weeks, followed by a months-long stay in a nursing facility.

White’s scenario is a perfect illustration of a “never event,” something that “should never happen inside the protective embrace of a hospital,” Ryan writes, and although it didn’t work in White’s case, Swedish Medical Center tries to avoid these “never events” by installing bed alarms that are wired to go off if a patient leaves their bed.

This is all well and good, the nurses’ unions are saying, but alarms are a band-aid. Swedish Medical nurse Bernedette Haskins is among the scores of nurses nationwide who are saying “medical mishaps of all kinds often share a root cause: understaffing.”

Hospitals disagree, Ryan reports, and “the unions are pushing state and federal legislation to force hospitals to beef up nursing staffs. Hospitals say they can reduce errors without government-mandated hiring.”

Nurses in Washington point to Auburn Medical Center, which had the most falls in the state.


“Last year, after new owners bought the small hospital, they overhauled its safety procedures and increased staff by more than 100. Hospital management says Auburn’s rate of falls fell by two-thirds in less than a year.”

According to Haskins, “Every nurse has a story about being short-staffed, about working an entire 12-hour shift without a break.”

If hospitals want to prevent “never events,” it’s not a fancy piece of new technology that’s needed, they say. It’s more providers.

As healthcare executives, how do you respond to the nurses’ unions who are saying “never events” don’t occur because of unrefined technology, but because of understaffing? What is the situation at your organization? How do you avoid “never events”?

-by Pete Fernbaugh

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