Falls are considered “never events” under Medicare guidelines and of course are the subject of litigation against hospitals and other providers. The costs of overreaction to fear of being charged with error are not so readily measured, but are only too real:
If hospitals are scrutinized for the occurrence of falls, the natural tendency will be to focus on such events even at the expense of competing (and perhaps more important) outcomes. Unintended consequences are likely to include a decrease in mobility and a resurgence in the use of physical restraints in a misguided effort to prevent fall-related injuries.
[New England Journal of Medicine via KevinMD]
Wachter’s World (via KevinMD) reports on what can happen when promising innovations are too rapidly accorded the status of obligatory standards of care.
That’s what the federal government, if not common sense, says. But what if the fall is from the roof?
We’ve already aired much dissent from the medical profession about whether or not top-notch hospital care can in fact prevent all instances of patient falls, decubitus pressure ulcers (bedsores), hypoglycemia, deep vein thrombosis, delirium, suicide attempts, c. difficile infection, or iatrogenic pneumothorax. Nonetheless, Medicare has adopted its proposal to deny hospitals reimbursement for the cost of treating such events and complications, with likely consequences both for hospital behavior (refusal to admit some patients at high risk of never events), for private insurer behavior and for the climate of medical malpractice litigation. (Kevin Sack, “Medicare Won’t Pay for Medical Errors”, New York Times, Sept. 30). White Coat Rants, who has blogged extensively on the issue in past months, has some predictions (Oct. 1) of things we can now expect to see more of: more patient transfers between hospitals (since Medicare will not punish the second hospital for the first’s “never event”; underdiagnosis of certain conditions and overdiagnosis of others; and, more remotely but no less alarmingly, pressure on some families to serve as ultimate bearers of risk for supposed never events affecting the frailest and most elderly:
Say hello to the Advance Beneficiary Notices. Medicare won’t cover preventative care, so you are going to have to pay for it out of your pocket. If you’re prone to falls or bedsores, you’ll have to pay for a personal nurse to wait on you hand and foot so you don’t develop these never events. If you don’t pay for a personal nurse 24 hours around the clock to keep a never event from happening, you’re personally responsible for paying the costs of treatment if the “never events” occur. You had the opportunity to prevent the events but you were just too cheap to pay for it. I think that ABNs are less likely to catch on, but eventually I think they will become commonplace.
Thanks to a new city ordinance, they get to provide some of the world’s most expensive free hotel service to patients who are well enough to leave but refuse. (WSJ health blog, Aug. 4).
More: Numerous interesting comments from readers including this from Throckmorton:
This is not just in L.A. but happens all around the country as well. Our area saw this increase with the rise in nursing home suits. Nursing homes are now very reluctant to accept patients who are at risk for decubitus ulcers, etc. This combined with the declining revenue has led to the situation where there are no places that will accept transfers from the hospital. As more and more patients fill the wards awaiting placement, the hospital has no choice but to divert those that need urgent care.
You may not be able to get a nursing home patient out of the hospital, but at least you will not have a problem finding them an attorney.
Blood should never clot, microorganisms should never happen, and one doc-blogger is on a tear (Aug. 14, more, Aug. 17) over the sometimes absurd hype being given to the concept:
“Never events” are and always have been “all about the Benjamins.” Look at this news release. The “background” section states that the “never events” were “required” pursuant to Section 5001(c) of the Deficit Reduction Act. Medicare wants to stop paying for things not because they “should never happen” but because it’s trying to save money. The whole “never event” moniker is just a spin they put on the cuts to make it look like someone else’s fault. Do “never events” never occur at government run hospitals? We’ll never know because CMS doesn’t even include government run hospitals on the “hospital compare” list.
…or the universal adoption of round-the-clock patient guards or restraint devices, it’s hard to go along with the notion that hospital falls should be so-called “never events”. (Happy Hospitalist, Jan. 15, Feb. 20). Nor is the concept much more useful when it comes to patient suicide attempts or hypoglycemia, among other misadventures (White Coat Rants, Feb. 5)(via KevinMD). Related: letters section, 2004 (pressure wounds/bedsores).