Two Never Events In One Day

So I had the wonderful opportunity to be the doctor on record of two Medicare Never Events in one day. According to Medicare, these are events that should never happen. Events that any lawyer or lay person would interpret to mean malpractice. Hey, it should never happen. Right? Let's sue their asses. That's what labeling something as a never event does. Even with the covert purpose of saving money, not increasing patient safety. The patient safety goal is but a cover for their cost saving expedition.

So what happened to my patients?

One of them fell despite the  hourly rounding by the nurses.  Fell trying to get up to use the rest room. Fell while nobody was in the room. Fell out of confusion. A patient who was not previously confused. She got a huge extracranial hematoma. No intracranial concerns. But what would happen if she did? What if she sustained a life threatening subdural hematoma? What if she sustained a hip fracture? What if she sustained a pneumothorax and required a chest tube.

None of that would be paid for. The patient could rack up thousands of dollars in consumption of OR time, supplies, equipment. None of it would be paid for. Why? Some how a patient falling is considered failure of the nurses and doctors to prevent it. Impossible.

I like to look at never events with the following train of thought. Can the never event happen at home? If the answer is yes, it cannot be a never event. It is a natural event. Even the criminal events that nobody can foresee are considered never events. Tell me how a hospital can prevent a random crazy  family personality or hospital guest from going berserk and assaulting an employee or patient. It's impossible to predict or prevent. Yet the Medicare National Bank would like you to believe it is.

My second patient developed a venous embolism after a hip surgery, in spite of being on appropriate prophylaxis according to the Chest guidelines. Again, patient gets a bad outcome from a well documented complication of a medical illness and all of the sudden the connotation of a never event places blame directly on the backs of the nurses and the doctors. It is a haven of jackpot lotto lawsuits just waiting to happen.

No matter what you do as a physician, follow all well documented protocols to prevent complications, you can't expect 100% success. Labeling a never event as such is not rational when the events cannot be prevented entirely.

If I have two never events which were not preventable, in one day, imagine how many never events happen every single day in hospitals all across the country. Complications of illness being converted to never events. Who's dumb idea was that?