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Can We Eliminate "Never Events" with Behavioral Assessments?

May 6, 2016

hospital.jpgWe’ve written in the past about healthcare’s struggles to build a real safety culture, and to successfully implement the type of consistent safety processes that work in other industries. This week we ran across a wonderful summary of the problem by Nicolas Argy, MD, JD: Why Do Never Events Happen All the Time?

A “never event” is a serious medical error or adverse event (for example, wrong site surgery or hospital-acquired pressure ulcers) that should never happen to a patient. The Centers for Medicare and Medicaid Services (CMS) defines never events as "serious, preventable, and costly medical errors."

I’d encourage you to read this great piece. Here are highlights (or lowlights?) from the article and the comments/discussion it started:

  • The third leading cause of death in this country is medical errors. A patient dies every 72 seconds due to a medical error – where is the outrage?

  • Argy has served on numerous quality and safety committees and is “incredulous how frequently never events occur.”

  • The root cause analysis typically reveals that there has been a failure to follow the basic safety protocols; not doing the time out, failing to check a wristband, not double checking medication orders, etc.

  • Most major events aren’t because of a failure of process, but because of unsafe attitudes toward safe practices rooted in the desire to “get the job done.”

  • Often this is related to the individual’s failure to recognize his or her own shortcomings, including the propensity to take shortcuts. Why, WHY – would anyone in hospital fail to wash their hands, follow universal precautions, or take the surgical time out, EVERY TIME?

  • Nagy points out: “We cannot change policies and procedures, adopt the use of an electronic medical record and then allow recidivist human behavior and the impetus of the status quo to thwart our efforts to protect patients.”

Download our whitepaper about the individual behaviors that drive patient safety and the patient experience

Here’s what we know from our work in other industries:

  • Safety is dependent on human behavior

  • We can change human behavior

  • The first step toward changing human behavior is understanding behavioral tendencies.

  • For instance, we’ve demonstrated that specifically-designed behavioral assessments can identify employees most prone to being involved in work-related safety incidents – it’s ground-breaking work in the manufacturing and energy sectors.

To date, our healthcare clients have asked for behavioral tools to improve turnover and the patient experience – and we’ve been providing them. The next horizon in healthcare behavioral assessments? Patient safety – we will be able to help employees to understand their own behavioral tendencies so they can overcome them and make never events, truly “never.”

Patient Safety

See some of our previous blogs on this issue:

6 Things about Patient Safety That You Can Learn from Other Industries

Are Hospitals Really Serious About Patient Safety?

Patient Safety: Can We Learn Something from Utility Companies?

Or, see some of the fascinating work we've done predicting, and changing, safety behavior in other industries by clicking here.


Bryan Warren Bryan Warren is the President of J3 Personica, a consulting, assessment, training, and coaching firm, and a guest blogger for PSI. Bryan is an expert in progressive talent strategies, with a particular focus on leader and physician selection and development.