Thursday, October 16, 2008

Never Events on a Serious Note

Tongue-in-cheek post aside, as I was looking through the list of never-events on the cms website, I was blown away by this one: "patient death or serious disability associated with patient elopement for more than four hours."

Isn't the very definition of "patient elopement" that they leave without anybody knowing about it?  Because if we know about it, then we tell them that we don't want them to leave and then it is called leaving against medical advice and we usually get a signature.

Then there is "suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility."  I can understand this one if a patient is known to have or at least show signs of SI, but working in an ER, I know from family members and loved ones that many many times people show no outward signs right up until the moment that they carry out their plans.  Sure, many times you can go back in retrospect and say, oh, she was calling out for help by buying a new car or whatever, but it seems that cms wants nurses to be telepathic or they wont pay.

Another one that blows me away is "Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy."  What? So because someone meets the artificial definition of "low-risk pregnancy" they can never have complications?

And then there is the infamous "restraint or bedrail" use that discourages the use of (you guessed it) restraints and bedrails.  I've seen the guilt-laden videos in training classes trying to make us feel really bad about the patient who climbed over the bedrail and fell to the ground and oh how tragic, ignoring the fact that were it not for the bedrail, the patient would have simply fallen to the ground without having to go to the effort of climbing over anything.  Invariably, they recommend a bed-alarm instead, so that at least by the time the patient is falling toward the ground and toward the inevitable OR ortho suite, the staff can already be on the way in to the room.  And invariably, these kinds of rules get taken to the extreme.  I remember back in my dark days of working in a Nursing Home that several patients had the wonderful dignity of being able to sleep on a thin mattress on the floor.  No kidding.  That's how I want to live my last several years.  I wonder who will pay for the chronic back pain developed by the nurse who has to change Mrs. Johnston's diaper?

But what really makes me the most angry about the never events, are that so many of them are just an example of our society moving further and further away from personal responsibility.  Yes, ostensibly it seems that they are encouraging institutional responsibility, and yes, many of the never events are truly events that are caused by negligence on the part of healthcare workers, but so many of them involve the absolution of personal responsibility by patients that it is disgusting to me.  For instance, a hospital can do everything in its power to keep an endotracheal tube free from infection, but when the concerned family member gets concerned by something and places his grimy hands all over the tube, what is the hospital to do?  Or when a patient elopes... now that's my fault?  Or if a deep vein thrombosis develops after surgery because the idiot patient is non-complient with the range-of-motion machine, or goes home and doesn't move around like they should, heaven-forbid that person be blamed for his own actions.  And of course the ultimate is the suicide one, because nobody should ever have to be held responsible for their own decisions.  We should solve all their problems for them.


girl_in_greenwood said...

My favorite is pressure ulcers on a 300+ pound patient who flatly refuses to turn off his bum no matter how many gory stories I tell him about weeping sores on sacrums. Clearly, that is ALL MY FAULT.

Braden said...

well, you should know better.

CountyRat said...

"patient death or serious disability associated with patient elopement for more than four hours."

Huh? I thought that the mentally competent adult patient has a legal right to take a hike if he wants to. We are nurses, not prison guards. We have no legal authority to stop anyone from going anywhere.

If that is true, and I do something to prevent this never-never-land event (something more than saying, "oh please, don't go!") I would be at risk of an accusation of assault, or perhaps, abduction.

No thanks.

Tom said...

Nice Blog. Check out the AHRQ web site for additional information on elopement. Here is a definition:

Elopement—legally defined as a patient who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected.