A commentary in NEJM cites evidence that at best only 20% of hospital falls, a currently designated “never event,” can be prevented. Concerning VTE, under consideration for addition to the list, Aggravated DocSurg provides evidence that some hypercoagulable patients are gonna clot despite appropriate VTE prophylaxis.
In its report on patient safety a decade ago the Institute of Medicine emphasized the need to move from a culture of blame to a culture of transparency. Instead, because of the never events initiative we've derailed transparency and taken the culture of blame to a new level. The patient safety movement has backfired. We're worse off than we were 10 years ago.
H/T to Retired Doc.