29 Mistakes That Should Never Happen In A Hospital, But Do

Massachusetts is well known as home to some of the world's most prestigious hospitals, such as Mass. General Hospital and Children's Hospital both recently named among the "Top Hospital in the Nation" by U.S. News & World Report and Best Hospitals.® However, even here in Massachusetts, serious medical mistakes continue to happen to far too many patients while in the hospital.

As a follow up to last year's post on Massachusetts Hospital Errors, we have updated our reporting to include new data (from 2015) that hospitals and surgery centers are required to report to the Department of Public Health documenting Serious Reportable Events or SREs. There are 29 such events, also known in hospitals as "Never Events," and we list them here with the total instances reported by the state's acute care hospitals in 2015. For similar information on non-acute care hospitals and ambulatory surgery centers please see the The Massachusetts Health and Human Services website for that publicly available information.

While the total number of SREs in acute care hospitals increased in 2015 (up from 89 in 2013; 82 in 2014; and 1,254 in 2015), most of the increase in 2015 was due to a spike in cases of contaminated drugs, devices or biologics, with most of those accountable to one hospital — Baysate Medical Center in Springfield, MA, where patients were exposed to infection due to unsanitary conditions in the inpatient dialysis unit. Patient safety efforts at hospitals aim at reducing errors, but still too many errors are happening.

In addition to the contamination events, topping the list of hospital errors in Massachusetts are:
  • Falls
  • Pressure ulcers
  • Medication error
  • Foreign object left behind (surgery)
  • Burns
Review the full list of Never Events below.

Massachusetts Serious Reportable Events

Surgery Events
1. Wrong body part, side or site surgery of procedure = 26
2. Wrong patient surgery or procedure = 2
3. Wrong surgery or procedure performed = 12
4. Foreign object left in patient after procedure unknowingly = 36
5. Death of ASA Class I patient during surgery or within 24 hours = 0

Product Events
6. Contaminated drugs, device or biologics = 448
7. Device misuse or malfunction = 12
8. Intravascular air embolism = 2

Patient Protection
9. Patient discharged to unauthorized person = 0
10. Serious injury or death during patient disappearance = 2
11. Suicide or self-harm = 31

Care Management Events
12. Serious injury or death from medication error = 54
13. Unsafe blood transfusion = 0
14. Maternal serious injury or death associated with labor or delivery = 10
15. Newborn serious injury or death associated with delivery = 15
16. Serious injury or death after a fall = 309
17. Stage 3, Stage 4 or unstageable pressure ulcer = 228
18. Artificial insemination with wrong egg or sperm = 0
19. Serious injury or death from loss of irreplaceable biological specimen = 1
20. Serious injury or death from lack of follow up or communication of lab result = 3

Environmental Events
21. Serious injury or death from electric shock = 0
22. Oxygen or gas delivery error = 0
23. Serious injury or death from burn = 30
24. Serious injury or death from physical restraints = 1

25. Serious injury or death from metallic object in MRI  = 2

Potential Criminal Events
26. Impersonation of a health care provider = 0
27. Abduction of patient = 0
28. Sexual abuse or assault of patient or staff member = 9
29. Serious injury or death after physicial assault of patient or staff = 21

How Did Your Hospital Do?
For a hospital-by-hospital tabulation of the most recent “never event” medical errors, please visit the mass.gov website’s Serious Reportable Events page.

Hospitals and ambulatory surgery centers are required by law to report SREs to the Massachusetts Department of Public Health. The law also prohibits hospitals from charging for these events or seeking reimbursement for SRE-related services. 

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Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law. Attorneys practicing in MA, NH and RI.

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