Twenty-Eight Categories Of Preventable Medical Mistakes

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The National Quality Forum (“NQF”) is a consensus standard setting organization that has published a list of 28 adverse medical event categories that should never occur in a hospital setting. The list of events has been embraced by 11 states that have directed hospitals not to charge patients or insurance companies for these categories of preventable mistakes. Unfortunately, neither Connecticut nor its hospitals have endorsed this program. Nevertheless, we have listed the 28 categories of “Never Events” as a preliminary “qualifier for patients and family members interested in further investigating potential medical malpractice claims in Connecticut. The categories are as follows:

1. Unintended retention of a foreign object in a patient after surgery or other procedure

2. Patient death or serious disability associated with patient elopement (disappearance)

3. Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)

4. Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products

5. Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility

6. Patient death or serious disability associated with a fall while being cared for in a healthcare facility

7. Surgery performed on the wrong body part

8. Surgery performed on the wrong patient

9. Wrong surgical procedure performed on a patient

10. Intraoperative or immediately post-operative death in an ASA Class I patient

11. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility

12. Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended

13. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility

14. Infant discharged to the wrong person

15. Patient suicide or attempted suicide resulting in serious disability, while being cared for in a healthcare facility

16. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility

17. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility

18. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates

19. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility

20. Patient death or serious disability due to spinal manipulative therapy

21. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances

22. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility

23. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

24. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider

25. Abduction of a patient of any age

26. Sexual assault on a patient within or on the grounds of the healthcare facility

27. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility

28. Artificial insemination with the wrong donor sperm or donor egg

An injury or death resulting from one of the category of events does not necessarily justify bringing a malpractice claim. However, it does present an opportunity to further explore the viability of a medical malpractice claim.

By Stewart Casper. Posted August 13, 2008

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