A concerned mother called local law enforcement when her 42-year-old son was threatening to take his life.  Law enforcement transported the apparent suicidal man to a local hospital with a behavioral health unit. While in the emergency room, full suicide precautions were taken and the patient was under watch at all times. After he was admitted to the behavioral health unit, the staff of the behavioral health unit failed to monitor the patient on a regular basis.  As a consequence, utilizing his sweatpants and a plumbing fixture as a ligation point, the man strangled himself to the point of near death.  By the time he was found he had a very low level of functioning. Despite heroic efforts he died several days later.  The behavioral health unit failed to monitor a suicidal patient under its care.  Suicide by any patient in a behavioral health unit is classified as a sentinel event or a “never event.”

Our office undertook the representation of the distraught mother for the death of her son and instituted proceedings.  In relatively short period thereafter the hospital along with the Patient’s Compensation Fund agreed to a satisfactory settlement for the medical negligence case/wrongful death for the mother.

The Patient’s Safety Network describes 29 serious reportable events grouped into 7 categories.

Product or Device Events

• Patient death or serious injury associated with the use of contaminated drugs, devices or biologics provided by the healthcare setting.
• Patient death or serious injury associated with the use or function of the device used in patient care, in which the device is used for functions other than intended.
• Patient death or serious injury occurring with intravascular air embolism that occurs while being cared for a patient in a healthcare setting.

Patient Protection Events

• Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person.
• Patient death or serious disability associated with patient elopement (disappearance).
• Patient suicide, attempted suicide, or self-harm resulting in serious disability while being cared for in a healthcare facility.

Care Management Events

• Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration).
• Patient death or serious injury associated with unsafe administration of blood products.
• Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting.
• Patient death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy.
• Artificial insemination with the wrong donor’s sperm or egg.
• Patient death or serious injury associated with a fall while being cared for in a healthcare setting.
• Any Stage III, IV, or any unstageable pressure ulcers acquired after admission/presentation to a healthcare facility.
• Patient death or serious disability resulting from irretrievable loss of an irreplaceable biological specimen.
• Patient death or serious injury resulting from following up or communicating laboratory, pathology, or radiology test results.

Environmental Events

• Patient or staff death or serious disability associated with an electric shock in the course of patient care process in a healthcare setting.
• Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances.
• Patient or staff death or serious injury associated with a burn incurred from any source in the course of patient process in a healthcare setting.
• Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a healthcare setting.

Radiological Events

• Death or serious injury of a patient or staff with the introduction of a metallic object into the MRI area.

Criminal Events

1. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider.
2. Abduction of a patient/resident of any age.
3. Sexual abuse/assault on a patient on or within the grounds of a healthcare setting.
4. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting.

Most never events are rare.  However, when never events occur, they are devastating to patients.  71% of the events that are reported to the Joint Commission on hospital accreditation over the past 12 years were fatal. These sentinels or never events may indicate a fundamental safety problem within an organization.  Although individual events are uncommon, on a population basis, many patients still experience these serious errors.  A 2013 study estimated more than 4,000 surgical never events occur yearly in the United States.  The Joint Commission on hospital accreditation has recommended that hospitals report “sentinel events” since 1995.  Sentinel events are defined as an “unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof.”  The NQF’s never events are also considered sentinel events by the Joint Commission.  The Joint Commission mandates a root cause analysis after a sentinel event.  The Leapfrog Group recommends that in addition to a root cause analysis, organizations should disclose the error and apologize to the patient, report the event, and waive all cost associated with the event.

If you or any of your family members have suffered injury or death by any of the described “Never events” while under the care of a healthcare provider, contact Kopfler and Hermann for a prompt evaluation.  We have the tools, expertise, and knowledge to bring about a swift resolution for any “Never event” or “Sentinel event”.