New Year’s Resolution: Hospital Moving Away from Term “Never Event”… Due to Frequency of Events
NAPLES, FL – In 2011 when the term “Never Event” came into vogue for certain medical and surgical “whoopsies” that probably should never happen, administrators and quality care advisors at Our Lady of Perpetual Infirmity hospital in Naples, FL were quick to latch on to this “hot button” concept.
“Look, we thought if we started to invoke this ‘Never Event’ idea at staff meetings and departmental debriefings we could fear-monger our way into compliance with the surgeons and meddies alike,” explained Dr. Ned Sneevely at the 2015 annual shareholders meeting in Boca Raton.
“It’s really back-firing,” the non-practicing surgeon turned full-time safety officer continued, “Turns out no matter how much we threaten these practitioners with sanctions and pay-for-performance, if you take off Granny UTI’s wrist restraints to stay in JCAHO compliance, you are going to lose 1 or 2 of them down the elevator shaft on 3South where there is a faulty door-closing mechanism.”
Sneevely, now impersonating a delirious elderly patient with his best “walking dead” style zombie gait, continued, “Quite honestly I can’t keep up with the paperwork. I think the smell of muffins wafting up from the cafeteria is drawing them towards the elevator shaft. In the 4th quarter alone we lost 3 silverbacks down there,” offered Sneevely, likening octogenarians to aged primates. “I’m getting a lot of pushback from the Nurse’s union for saddling them with this problem.”
“Take the OR, for example,” continued Sneevely, who prior to “retirement” led the league in wrong-site surgery. “No matter how many fire safety videos and webinars we throw at the OR staff, fires keep sprouting up all over the day surgery center on a weekly basis….It’s like the movie “Backdraft” in the eye surgicenter,” said Sneevely. “You know, the new addition that has the leaky oxygen regulators and ceiling mounted dangling electrical outlets,” he explained.
“Let me ‘bottom line’ it for you,” concluded Sneevely, whose use of air quotes had become a bit off-putting to the on looking board of directors, “either we accept the fact that the occasional lap pad gets left behind in Johnny gunshot wound’s abdominal cavity and we cut him a check, or, we call it a ‘Never Event’ and have to report it to some board and make a big thing out of it with root cause analyses and whatnot. We only had 4 retained foreign bodies in Fiscal Year 2015, I don’t think that should force us to have to buy some electronic lap pad counting device or some such nonsense.”