Decubitus Ulcer declared a “Never Event” in Healthcare

Decubitus Ulcers should “never” occur

Decubitus ulcers (bedsores) have been determined to be a “never event” in hospitals and nursing homes. This means they should never occur and can be prevented.

Most Never Events are very rare. A recent study estimated that a healthcare providers may have a “never event” of wrong-site surgery once every 5 to 10 years. Despite the rarity, when never-events occur, there are horrific patient consequences. 71% of never events reported to the Joint Commission over the past 12 years were fatal. If there are reoccurring “never events” that occur in a nursing home or hospital, this may indicate a negligent healthcare environment.

decubitus ulcer never event

Decubitus ulcers (bed sores) are “never events” in healthcare

The Joint Commission requires “never events” like pressure sores be reported. The Joint Commission also requires that the staff perform a root cause analysis after the never event occurs. In other words, if your loved developed a pressure sore, staff must conduct an analysis/investigation as to how the decubitus ulcer formed. The Leapfrog Group recommends that in addition to an investigation, healthcare providers should tell the patient’s family about the error and apologize to the patient, report the event, and waive all costs associated with the event. Interestingly, CMS (Medicare) has withdrawn medical payments for “never events” like a bedsore forming in a hospital.

Never Events like decubitus ulcers are devastating and preventable, therefore, nursing homes and hospitals are under increasing pressure to eliminate them completely. The Centers for Medicare and Medicaid Services (CMS) announced in August 2007 that Medicare would no longer pay for additional costs associated with many preventable errors, including those considered Never Events like decubitus ulcers.

Pressure sores are a “never event.” As a pressure sore lawyer, I know the frustration you feel in learning that this kind of wound is easily preventable. If you or a loved one has developed a bed sore, click here to learn about your rights in a pressure sore lawsuit.

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