Calif. Hospitals Scaling Up Efforts To Prevent Medical ‘Never Events’
California regulators and health care officials are ramping up efforts to reduce the number of "never events" that occur at hospitals, the San Francisco Chronicle reports (Colliver, San Francisco Chronicle, 6/2).
Since July 2007, state law has required hospitals to submit reports to the Department of Public Health about never events, or medical errors that are never supposed to happen. California hospitals reported 2,446 adverse events between July 1, 2007, and Dec. 31, 2009, according to DPH.
A report prepared for the Legislature earlier this year found that the most common never events reported by California hospitals are severe bedsores, followed by foreign objects left in surgical patients (Hines, Riverside Press-Enterprise, 6/1).
Hospitals have financial incentives to prevent never events because state regulators can issue administrative penalties for such errors. In addition, CMS in 2008 stopped reimbursing hospitals for the treatment of patients who experience never events.
Using Fines To Promote Patient Safety
Since 2007, the state has issued 156 administrative penalties to 108 hospitals. So far, the state has collected $2.9 million of the $4.8 million it levied in fines (San Francisco Chronicle, 6/2).
Officials say the state intends to use $800,000 of the fines it has collected to establish a program to help hospitals reduce cases of foreign objects left in surgical patients (Riverside Press-Enterprise, 6/1).
The funds have received approval, but they will not be available until the state budget is signed (San Francisco Chronicle, 6/2).
Steps To Prevent Never Events
Kathleen Billingsley, deputy director of the public health department's Center for Health Care Quality, said the public disclosure of never events and the administrative penalties have spurred hospitals to take steps to improve care quality (Riverside Press-Enterprise, 6/1).
For example, San Francisco General Hospital stopped using small sponges for abdominal surgeries and started performing low-dose X-rays to scan for retained objects after the facility received a $25,000 fine for an incident in which a sponge was left in a surgical patient.San Francisco General also instituted a new policy requiring members of the surgical team to examine incisions before closure and allowing any team member to call for an equipment recount at any time. The hospital has reported no retained foreign objects since enacting the new procedures (San Francisco Chronicle, 6/2). This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.