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Navigating Health Care: Avoiding 'Never Events'
Rand: Medical errors, especially so called "never events," are one of the
Nation’s leading causes of death and injury. As we continue speaking with AHRQ
Director Dr. Carolyn Clancy, we’re talking about ways that patients can reduce
their risks. Dr. Clancy, many consumers have heard the health care term "never
event," but may not understand exactly what it means. Would you please explain?
Dr. Clancy: Never events are mistakes that should never happen in health care,
such as serious post-surgical blood clots, surgery on the wrong body part, or
the right surgery but the wrong patients. You know, most people expect that when
they go to the hospital, they won’t come out sicker than when they went in, but
unfortunately this isn’t always the case. Medical errors continue to be a real
problem in our health care system, and never events, although rare, are
particularly serious.
Rand: So what’s being done to improve the problem?
Dr. Clancy: The federal government no longer pays hospitals for additional care
a patient needs when one of these never events happens. This is based on a new
Medicare rule that began October 1, 2008. This policy is about improving the
quality and safety of patient care by paying for good care, not just more care.
Certainly, a patient should never have to pay for care that results in more harm
than good.
Rand: Is there anything that consumers can do to help reduce their risks of a
never event?
Dr. Clancy: Consumers can help lower their likelihood of experiencing a never
event and increase the overall quality of care they receive by being active in
their health care. That means taking part in every decision about your health
care and asking lots of questions. Research shows that patients who are more
involved with their care tend to get better results.
Rand: Part of this has to include patient education. Where can consumers start
to find out more information?
Dr. Clancy: AHRQ offers some very helpful resources for consumers. For example,
we have a great patient fact sheet called "Five Steps to Safer Health Care,"
that we developed in partnership with the American Hospital Association and the
American Medical Association. Our top advice, though, is "ask a lot of
questions." Choose a clinician that you feel comfortable talking to, and always
make sure that you get the answers you need. Remember, you are in charge of your
health care. I’m Dr. Carolyn Clancy, and that’s my advice on how to navigate the
health care system.
Rand: For these guides and more, check out AHRQ’s Consumer and Patients Web site
at ahrq.gov/consumer.
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