Jordan Rau at the Los Angeles Times has an important article (with lots of links to primary source documents!) on the key issue of “never events”–those things that should never, ever happen when you get care.
It’s a list that includes getting severe ulcers from bedsores, having equipment left in a person during surgery, undergoing the wrong surgery or having the wrong limb amputated, or being given the wrong medication or wrong dosage. Unlike other parts of the art of medicine, these are problems that are preventable if the systems are in place.
The number of these adverse events reported is over 1,000 in a 10-month period. It’s a wake-up call–Many in the health care community would not have predicted such a large number. These medical errors are serious–in some cases, deadly serious. By definition, these are “never” events–not “sometimes OK” events.
The article highlights AB2146 (Feuer), an important bill supported by many consumer groups like Health Access California, AARP, CALPIRG, Consumers Union, as well as business and labor organizations. It would have California follow the federal government in not paying for these adverse events, as part of a shift to change the financial incentives in this category.
I would also add AB2967 (Lieber), which would add more transparency to the cost and quality of the care being provided in California. This information is valuable in its own right, and will have a impact in getting hospitals to prevent these errors, which will improve health outcomes, and save money too. Information shouldn’t be the only tool, but it should be part of more aggressive oversight.
Read the article. It’s worth your time.