Mar 14, 2016
Having served on multiple quality and safety committees and visited dozens of institutions to discuss never events, I am incredulous how frequently "never" events occur. The root cause analysis typically reveals that there has been a failure to follow the basic safety protocols which are in place; not doing the time out, failing to check a wristband, forgetting to put up a railing, not double checking medication orders, not assessing skin integrity, etc
A simple intervention can forever eliminate many never events. A recent article in the New York Times, describes the mandate for doctors prescriptions to be electronic or face fines or even criminal sanctions. While the impetus in New York is to limit fraud and opioid abuse, the requirement for electronic ordering has a more extensive salubrious impact. The problem of poor handwriting as a cause of untold suffering and thousands of deaths has been well described. The fix is easy and straightforward and New York is on the right path.
A recent panel meeting I attended reported a never event caused by poor handwriting and when I asked how this happens in the age of the digital record, I was told that the hospital had succumbed to pressure to allow clinicians to fax in handwritten orders. Frankly these exceptions for expediency can not be permitted. We need to "Just say no!" We must follow established safety protocols
The third leading cause of death in this country is medical errors. I am dismayed that this is not on the front page of the papers or in social media all the time. To make never events the exception rather than the norm, we must not tolerate business as usual. The statement that something cannot be done because, "That is not the way we do it " cannot be accepted. We cannot change policies and procedures, adopt the use of an electronic medical record and then allow recidivist human behavior and the impetus of the status quo to thwart our efforts to protect patients.
Creating hard stops, using neurocognitively validated interventions, adopting systems solutions with accountability are all available to solve our problems. Do we really need state legislation to make the changes? I hope not. We can and must do better.
Nicolas Argy, M.D., J.D. Copyright 2016