More states consider reports of 'never events'

Some medical errors are so egregious that lawmakers in four states now require hospitals to publicly report how often they occur, and to prove that they have taken corrective action. These "never events" laws adopted in Illinois, Minnesota, New Jersey, and Connecticut are based on criteria developed by the National Quality Forum (NQF).

NQF officials said that several other states are considering never events legislation, although not without some controversy. The Massachusetts House of Representatives, for example, recently passed legislation that requires publication of hospital quality data, but the state senate is considering a harsher never events law based on NQF standards.

The purpose of public reporting is to encourage hospitals to become aggressive in implementing evidence-based protocols that limit or even eliminate the preventable errors outlined by NQF. "Hospital pharmacists are in a position to be integrally involved in the quality improvement process that results from public reporting," said Kienle. "They have been increasingly involved in total patient care because they have the opportunity to observe the entire treatment process, through prescribing patterns. So they must take an active role in all the hospital committees responsible for patient safety."

Kienle said laws passed by the four states are encouraging. Minnesota was the first state to pass a never events law, soon after publication of the NQF report. The state's first public reporting was January 2005.

The results were grim. State hospitals performed surgery on the wrong body parts, gave the wrong medications, or made other mistakes that endangered patients 99 times in a 15-month period starting in the summer of 2003. The Minnesota health department report said that 20 deaths were associated with hospital errors, including eight people who died after falls and four after medication errors.

Thirty of the state's 145 hospitals reported the occurrence of at least one never event between July 2003 and October 2004, including the Mayo Clinic, which reported six never events at two of its hospitals, resulting in two deaths associated with medication errors.

Illinois is the most recent state to pass a never events law, in November 2005 as part of a hospital funding bill. Public reporting begins there on Jan. 1, 2008. After that date, hospitals and surgery centers will be required to publicly admit if they commit any of 24 types of the NQF never events, such as operating on the wrong limb, leaving a surgical sponge behind, using the wrong blood type, or causing a patient death with a medication overdose.

Under the law, which was supported by the Illinois Hospital Association (IHA), hospitals and surgery centers are also required to analyze the cause of and take corrective action within 30 days of each event. The names of patients and healthcare workers involved in any incidents will be confidential, and the state officials will not take disciplinary action for the mistakes.

Illinois passed several other laws in the past couple of years that open hospitals up for public inspection. For example, the state's hospitals will be required to report infection rates, nurse staffing, mortality rates, and quality data pertaining to 30 common procedures. IHA supports such measures because they help hospitals learn from their mistakes and create a culture of safety, said IHA senior VP for government affairs Howard Peters.

"Public reporting accountability leads to improved quality," said NQF spokesman Philip Dunn. "We know this to be the case, if for no other reason than you can't control what you don't measure."

THE AUTHOR is a healthcare writer based in Gettysburg, Pa.