Superman was the victim of a medical mistake.
Sound far-fetched? The Man of Steel survived a spinal cord injury so severe that it left him paralyzed from the neck down for the last nine years of his life — years that he spent actively defying his doctors’ dire predictions by living an active life and advocating for medical research.
Ultimately — under the care of his devoted wife and the best doctors money could buy — Christopher Reeve died from a pressure ulcer, more commonly known as a bed sore. The infections that can result from bed sores are not uncommon. Obese patients and victims of paralysis are often confined to the same positions for extended periods of time, and pressure ulcers can develop even under the best medical care.
But under a new Medicare rule that will take effect October 1, 2008, Reeve’s death would be attributable to a medical error. And Medicare has announced that it will no longer reimburse hospitals for remedying a specific list of events — including pressure ulcers — that CMS deems preventable.
So what does this mean for you?
Pressure ulcers are on a list of 28 medical errors, or “never events,” defined by the National Quality Forum (NQF) in 1992 as preventable medical mistakes that the forum says should never occur in a hospital (see “Never Events” text box). In addition to pressure ulcers, these events include medication errors, falls, and much more egregious mistakes such as wrong-site surgeries.
| ‘Never Events’ as Defined by the National Quality Forum 1. Unintended retention of a foreign object in a patient after surgery or other procedure. 2. Patient death or serious disability associated with patient elopement (disappearance). 3. Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration). 4. Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA- incompatible blood or blood products. 5. Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility. 6. Patient death or serious disability associated with a fall while being cared for in a healthcare facility. 7. Surgery performed on the wrong body part. 8. Surgery performed on the wrong patient. 9. Wrong surgical procedure performed on a patient. 10. Intraoperative or immediately post-operative death in an ASA Class I patient. 11. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility. 12. Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended. 13. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility. 14. Infant discharged to the wrong person. 15. Patient suicide, or attempted suicide, resulting in serious disability, while being cared for in a healthcare facility. 16. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility. 17. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility. 18. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates. 19. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility. 20. Patient death or serious disability due to spinal manipulative therapy. 21. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. 22. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility. 23. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility. 24. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider. 25. Abduction of a patient of any age. 26. Sexual assault on a patient within or on the grounds of the healthcare facility. 27. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility. 28. Artificial insemination with the wrong donor sperm or donor egg. |
