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Never events in Maryland hospitals: part 1

There are certain types of incidents that patients should never experience while in a Maryland hospital. According to the Agency for Healthcare Research and Quality, that is why these are called never events, and patient safety experts have determined that these mistakes and the harm they cause are preventable.

There are approximately 4,000 of these cases happening during surgery in the U.S. each year. They also occur because of the following:

  •          Medication errors or contamination
  •          Falls
  •          Lost test results or failure to follow up on tests
  •          Product device malfunctions
  •          Bedsores acquired while in a health care facility
  •          Unsafe blood transfusions

In most cases, reports indicate that the problem leading to events should have been prevented through better safety at the organization level, rather than being a problem confined to a single staff member or provider. When the issue causes a serious injury or trauma, or death, or it creates that level of risk to the patient, it is known as a sentinel event.

The Joint Commission notes that sentinel event reporting to the agency is recommended, but hospitals are not required to do so. Health care organizations may follow the official policy developed by the Commission, although it is also not mandatory. Self-reporting a sentinel event allows a hospital to take advantage of the support offered through the agency, as well as sending a message of transparency and commitment to improving safety to the public.

Any sentinel event should be investigated immediately, regardless of whether it is reported to the Commission. 

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