Never events need to account for pre-existing medical conditions

Expanding never events to include conditions that may not be totally preventable is bound to invite controversy.

I wrote about the issue previously in USA Today, saying, “despite impeccable care, some hospital complications cannot be prevented.”  I cited the facts that no studies exist that show how infections can be cut to zero, and even the government acknowledges that there are few effective guidelines to reliably halt the onset of delirium.

In a recent New York Times piece, Pauline Chen takes up the problem, citing some new data. Indeed, according to the Archives of Surgery,

data from almost 900,000 cases in over 1,000 hospitals and found that patient characteristics could have a marked impact on the rate of several of these payer-specific “never event” complications. Pre-existing conditions like diabetes, chronic lung disease or malnutrition rendered patients more susceptible to certain complications no matter how much the physician intervened.

Instead, some argue for a “warranty” of sorts, that accounts of pre-existing medical conditions: “The warranty would be an all-inclusive upfront payment that would take into account the probability of having a complication, as well as the patient’s prior condition; and it would be standardized according to what the best quality hospitals pay for the same diagnosis, procedure and complications.”

Using such a blunt instrument, like globally denying payment for never events, will only lead hospitals and doctors to cherry-pick patients, leaving the ones more prone to complications to safety net hospitals. These unintended consequences can be minimized if those making the rules accounted for the nuance that quality medical care demands.


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  • Anonymous

    Never events, although “sounding” great to the American public, are really just another way to limit payments to hospitals instead of directly cutting payments. Lets make a set of conditions that is unobtainable, and when you do not obtain these unobtainable conditions, we will cut your payments. Instead of just cutting payments directly and saving all the paperwork and wasted effort.

  • Doc D

    The concept of “never” events may have been a (moderately) good one in the beginning: operating on the wrong leg, for instance. But when the list was expanded to include “unfortunate, but sometimes unavoidable” events like catheter infections, despite the best care, in patients who are at risk for these complicaitons, the initiative ran off the rails.

    I don’t question the original motives, to lower the rate of medical errors. But now it’s about money.

  • MG

    Yes! Let’s bring some good sense to policy. I think this has been a general sentiment among health care providers ever since Medicare instituted its expanded list of never events.

  • fortitude

    this is another example of non-physicians telling us how to practice, when we were in residency training we had experienced physicians telling us what is the right thing to do and how to practice. Now as a private practioner we have MBA’s and lawyers dictated how me must practice.

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