In 2001, Dr. Ken Kizer, MD of the National Quality Forum first coined the phrase “never events” to define various types of medical errors that are inexcusable and therefore should never occur.
Wrong-site surgery, operating on the wrong patient and medication treatments are among the types of mistakes that make up the list of never events. Despite Mr. Kizer’s clever terminology for these mistakes, never events are actually somewhat common in the United States.
A USA Today investigation into medical mistakes in the healthcare industry revealed that one of the most disturbing and unsanitary types of never events is putting Americans at risk of developing deadly diseases during otherwise routine health care procedures: dirty needles.
‘Never Events’ Violate Basic Standards of Care
In the United States, we have a wide range of stringent rules and regulations concerning sanitation in healthcare facilities. These standards ensure that patients are treated individually without being exposed to any illnesses or diseases carried by other patients that are being treated. Although a majority of injections are performed safely under the adopted standards, recent information suggests that a significant portion are putting people at risk of serious illness and even death.
According to a recent report published by USA Today, more than 150,000 patients in the United States have been exposed to unsafe injection methods since 2001. Furthermore, two-thirds of these unsafe injections have been administered in the past four years, according to data from the Centers for Disease Control and Prevention (CDC).
The idea that a needle being used to deliver a flu shot or vaccine could potentially be contaminated with MRSA, HIV or hepatitis is likely implausible to many innocent patients, especially in such a medically advanced country as the United States. But as the CDC’s data shows, hundreds of thousands of Americans have been exposed to life-threatening diseases during routine medical procedures.
CDC Finds Trends in Data
Weighing in on the results of the report, CDC Associate Director for Infection Control Michael Bell says that while the CDC is focused on combating complex issues in healthcare safety, the seemingly obvious never events continue to occur and put patients at serious risk.
“It makes us crazy,” says Bell. “We’re trying to eliminate a range of harms in healthcare – high level, complex challenges – and we look behind us and these basic, obvious, completely preventable problems are still occurring. It really comes down to a matter of greed, ignorance or laziness.”
According to the USA Today report, several studies on the topic of injection practices have found that more than five percent of American clinicians don’t follow appropriate safety procedures when it comes to injecting patients.
It’s even more disturbing that the count of 150,000 potentially exposed patients is likely just a fraction of the actual frequency. Since many injection-related illnesses take time to develop, and many times patients are unable to absolutely determine if they were infected by an injection, these types of cases often are underreported. But the data shows one consistency in the fact that clinics and smaller facilities are more likely to participate in subpar injection practices than larger facilities.
The fact that smaller facilities are the more common site of these types of never events can likely be attributed to budget factors, as it is likely more economically beneficial for smaller places to reuse needles.
H>owever, the fact that it puts the health and lives of innocent patients at risk is what makes unsafe injections a true never event, and something we hope to see diminish in the near future. It will be up to the healthcare industry as a whole to cause a shift, and in the meantime many medical malpractice lawsuits will likely be filed on behalf of the innocent victims.