"Never events" in Utah give behind the scenes glimpse of malpractice

The State of Utah has set up a system to collate data on tragedies that "never should have happened" in the state's hospitals.  Although the data is collected on a voluntary basis and therefore only sheds light on the "tip of the iceberg", this year's data are enlightening.  They include 57 deaths or major permanent losses of function that "never should have happened.

Iona Thraen, director of patient safety for the helalth department, estimated that 350-some events happen each year in Utah's 272,000 hospital admissions.  It represents a small--but still unacceptable--risk for the average patient.  Utah began collecting this data on a voluntary basis after the Institute of Medicine published a study which estimated that medical errors cause 98,000 deaths each year in the U.S. 

In Utah, one of these events was reported every six days and experts agree that this does not include events which were settled pursuant to a "confidentiality agreement" after litigation (that demand of confidentiality is a virtual given in successful malpractice claims that are resolved short of trial).  According to the Salt Lake Tribune, the claims in 2007 included nine surgeries performed on the wrong site or where the wrong surgery was performed. 

2007 claims also included seven incidents of leaving a foreign object in a patient and the removal of a hemostat from a surgery years earlier.  Six patients suffered serious injury in a fall caused by hospital staff while one patient was criminally denied medication.  One anemic patient expired in the E.R. while being given blood intended for another patient; his type was A+, but he received O+.  Another patient was burned during physical therapy.