What Should NEVER Happen in the Hospital

When you or a loved one enters the hospital is it with an attitude of trust that is rare in other circumstances? Frequently, people who consider themselves to be savvy consumers in other areas of their lives, ask few questions and do not speak up when they feel something has gone awry in the healthcare setting. Others are so skeptical and suspicious that it puts healthcare providers on edge, feeling that their every move is being scrutinized.

This skepticism steams from fear. Knowing that medical errors are the 3rd leading cause of death in this country makes that distrust more understandable. I think the key to having a more sane approach to things when you or someone for whom you are a caregiver is hospitalized is to have more real information.

One great source for helpful information about hospital care is from the Leapfrog Group. On Getting the Best Care, The Insider’s Healthcare Podcast Episode 4, I talk about the health safety ratings that the Leapfrog Group releases. You can see this information about your local hospital on the website Hospital Safety Grade. Recently, the Leapfrog Group released the 2019 Never Events Report.

In healthcare, a “Never Event” refers to harm that is caused to a patient from an event that literally should NEVER happen. Never Events include:

  • Surgery done on the wrong patient, the wrong surgery done on a patient, surgery done on the incorrect body part (for instance on the right leg as opposed to the left leg), or surgical instruments unintentionally left in a patient.

  • Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting and incorrect use of a patient care device that results in patient harm or death.

  • Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting, death or serious injury associated with patient disappearing from the setting, and release of a patient of any age, who is unable to make decisions, to someone other than an authorized person or caregiver.

  • Patient death or harm resulting from a medication error or from incorrect administration of blood products.

    This is by no means a complete list of the Never Events. The National Quality Forum compiled a list of 29 events that are considered always unacceptable in a healthcare setting.

How Can Consumers Prevent Errors? Reading this may make you feel even more skeptical or nervous about turning yourself or a loved one over to the healthcare system. And, while it is definitely the responsibility of the healthcare professionals to ensure that a Never Event never happens, patients and family members can help to protect themselves from these errors.

Of course, you will not be able to stop a surgical sponge from being left in your loved one during surgery, but there are other events that you can play a part in preventing: Wrong Surgical Site: Always be sure that the surgeon who is going to perform the operation marks the site of surgery immediately before you are taken into the OR. If you are having cataract surgery for example, the doctor needs to initial above the eye that is to be operated on. This is required for any surgery for which there could be confusion as to the correct site, such as right or left limbs. Wrong Surgery or Patient: Be an active participant in the consent process. Whether it is for your own surgery or for that of a loved one who may need help, pay attention to every aspect of the consent process. Be sure to read the name and description of the surgery or procedure, and to ask questions if there is any confusion about what you are reading. Do not feel rushed, pressured or embarrassed about taking up the doctor’s or nurse’s time. Also, be sure that the staff correctly identified you by name and birth date. They should be asking you your name and birth date and also they should be checking your wrist band. Look on the consent form to be sure that your name and birth date are correct on the form. Patient Physical Safety: If your loved one is at risk for self harm or for wandering away, try to have a familiar person at the bedside as much as is allowed. You can also ask for a sitter to be assigned to stay with your loved one. Make your concerns clear to the staff and if you feel that you are not being heard, ask to speak with the unit manager or the nursing supervisor. Do not leave the hospital feeling insecure or uneasy about someone’s safety because you are hesitant to be seen as the over-bearing relative. You can make your requests in a calm and respectful manner so as to not alienate the very people to whom you are entrusting care. Never argue with a staff member, if you are not getting satisfaction from a calm discussion simply ask to speak with someone up the chain of command. I know that it is difficult to be unemotional when you are concerned for someone you love, but anger and frustration on your part will not serve you well in this situation. If your loved one is unable to make decisions and is at risk for being discharged to an unauthorized person, be sure that your name and telephone number are at the bedside. In addition to having given your contact information on admission, you will need to verify with each shift that they have the correct information as to whom should be contacted. Tape your contact information above the bedside table as an extra precaution. Harm from Medication or Blood Administration Errors: If you or a loved one is in the hospital you need to be as vigilant about taking medications as you would be at home. In other words, you would not pick up an unidentified pill from your counter and swallow it (I hope that you would not!); so too, when you are greeted by a nurse with medication you need to have each identified. Ask what the name of the medication is and also ask what is the intended benefit from the medication. Frequently, nurses say, “Here is your heart pill.” That is not saying what the pill’s intended effect is. An acceptable answer would be along the lines of, “This is the medication that helps to regulate your heart rate and blood pressure, without it, your heart rate or blood pressure may get too high.” That is the sort of response that allows you to catch an error. If you do not have high blood pressure for instance, you might want to ask why you are taking this medication. If you know that your heart rate is generally on the slow side, you would not necessarily want to take a medication that would slow it further. If the nurse said, “This is the medicine that is for blood clotting,” again, it is not stating the intended effect. They should say, “This is to be sure that your blood does not form clots that can cause a stroke.” That information would let you object to taking it if you knew you had a problem with spontaneous or uncontrolled bleeding. Medication Allergies: If you have had a bad reaction to a medication, it is not necessarily an allergy. It is important to be honest with healthcare providers about both concerns about adverse medication reactions (extreme nausea, dizziness, etc) as well as about allergic reactions (including hives, itching, difficulty breathing, etc). Then be sure that you have an allergy band on your wrist in the hospital that identifies the medications that you are not to be given. Adverse and allergic reactions are another reason to always ask about the medications you are being given before you take them. Blood Transfusion Problems: If you or your loved one are receiving blood products, be sure that 2 nurses, or doctors have checked the blood label and your wrist band (usually a “blood band” is a red wrist band that has special identifiers on it). Also, bad reactions to blood products generally happen in the first 15-30 minutes of the infusion being started. Be sure to speak up if strange or distressing symptoms occur (suddenly feeling feverish, itching, hives, swelling of the lips or tongue are just some of the adverse reactions, although, they are rare). Never down-play any distressing symptoms that you think may be related to receiving blood products or medications.

Being an active participant when you are in the hospital is essential to being safe as a patient. If you are caring for a loved one who is unable to advocate for themselves, then you need to be the eyes and ears. Ask questions, write your concerns in a notebook that you can refer to when the appropriate healthcare provider is in the room. Doctors and nurses, as well as other hospital staff want to provide quality care. But anytime we are dealing with humans there can be inadvertent mistakes made. Staff being rushed, tired, or stressed in some other way may contribute to errors. Help your doctors and nurses to provide the best care by: >Limiting the number of visitors that are at the bedside at any one time. >Asking questions before or after they have completed a task, rather than interrupting them as they are examining the patient, or changing a dressing. >Interacting with the staff with an attitude of respect and trust; this doesn’t mean that you need to blindly follow and accept whatever is being done if it seems inappropriate. Instead, it means that if there is a problem, approach it from the viewpoint that you all want the best outcome and that you are not in an adversarial relationship with the staff.

As always, here at Getting the Best Care-we want you to be clear on your goals. Whether it is you that is the patient, or someone you love, you need to know what are your goals for the hospitalization. Goals will be different for each person and each hospitalization. But if you know for instance, that the goal for bringing your grandpa to the ER is to just have the cut on his head from a fall to be stitched up and it is not necessarily to have a lot of testing done-then it will be easier to know how to answer when the doctor suggests a CT scan or x-ray. Having your individualized healthcare goals known will make getting the best care a more simple process.

Tune into: Getting the Best Care, The Insider’s Healthcare Podcast. It is available here on the website as well as on Spotify, Google Play and iTunes.