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Never events in Maryland hospitals: part 2

In a recent blog post, we noted that patient safety is sometimes threatened or compromised in Maryland hospitals because of never events. At the law offices of Wilson & Parlett, our team often assists clients who have been harmed by medical mistakes or negligence in health care facilities.

According to the Maryland Office of Health Care Quality, any preventable incident that results in serious patient harm must be reported to the OHCQ before the fifth day after the event is discovered. The most recent report notes that in the fiscal year 2015, there were 252 patients in the state who sustained harm in hospitals. Half of the reported incidents for that year were falls and bedsores. The percentages of the total adverse events over a three-year period were as follows:

  •          Falls – 31 percent
  •          Delays in treatment – 26 percent
  •          Surgical events – 20 percent
  •          Airway events – 5 percent
  •          Medication errors – 4 percent

While Maryland does consider and track harm caused by delays in treatment as a sentinel event, other states do not. Delays include incidents such as failing to perform tests or examine results in a timely way, and late blood transfusions to anemic patients. Issues that caused delays frequently included problems with training, supervision, communication and chain of command.

As the Joint Commission reported nationwide, the Maryland OHCQ also found that health care facility procedures, policies and hospital culture were primarily responsible for the errors. This has prompted the recommendation that hospitals should analyze the root causes of the events, such as critical thinking errors, assessments and personnel issues. More information about medical malpractice is available on our webpage.

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