64 ‘never events’ reported by NH hospitals in ‘15

Number down 12 percent from 2014

Sixty-four people suffered serious, avoidable harm as a result of the treatment they received in New Hampshire hospitals that was unrelated to the reason they were admitted in 2015, according to the annual Adverse Event Report released Dec. 2 by the state Department of Health and Human Services.

State law requires New Hampshire to track 29 rare errors that are often called “never events” because they are never supposed to happen in hospitals.

They include burns, falls, surgery on the wrong patient or body part, items left inside a patient after surgery, assaults and pressure ulcers among others. 

Adverse events in New Hampshire hospitals decreased 12 percent in 2015 from the previous year, but are still higher than they were from 2010 to 2013.

Dartmouth-Hitchcock Medical Center in Lebanon has reported the most adverse events for each of the six years that the state has required such reporting. In 2015, Dartmouth-Hitchcock reported 16 overall events, which accounted for 25 percent of all 64 adverse events in the state, up from 14 in 2014.

Dartmouth-Hitchcock also had the most surgical events in 2015 with two surgeries on the wrong body part and two incidents in which objects were left inside a patient after surgeries, according to the report. The other 2015 events at Dartmouth-Hitchcock included eight pressure sores, three falls and one burn.

In 2014, Dartmouth-Hitchcock had 14 overall events with one surgery on the wrong body part, one surgery on the wrong patient, two foreign objects left inside a patient after surgery, five pressure ulcers, four falls and one that was lab-related.

Dr. George T. Blike, chief quality and value officer at Dartmouth-Hitchcock, said in an email that the report lacks critical information about the severity of events, from minor and temporary to serious and permanent.

He said of the 16 reported Dartmouth-Hitchcock events, all but one were minor and temporary. “Of course, saying that these cases were minor and temporary certainly doesn’t diminish the events. Even a minor temporary event has impacts on our patients and their families, and our goal remains zero events,” Blike said. “When looking at the total number of events at Dartmouth-Hitchcock or any other hospital, it is important to take into account how many patients the hospital sees and how sick those patients are. Dartmouth-Hitchcock sees the most and the sickest patients in the state.”

Newborn adverse events

One area of increase was in the category of death or serious injury to a newborn during low risk pregnancies, labor or delivery, but it doesn’t specify if the newborn died. Four newborn events were reported in 2015 and only two events total in the previous two years. The report said two newborn events were reported by Alice Peck Day Memorial Hospital, one reported by Cheshire Medical Center, and one by Wentworth-Douglass Hospital in 2015.

A 2013 national study estimated the number of premature deaths associated with preventable harm at more than 400,000 a year.

Dartmouth-Hitchcock’s Dr. Blike said the hospital works to eliminate adverse events by learning from past ones and improving procedures.

“The safest hospitals reduce the harm that patients suffer from any given event by learning from those events to improve processes and procedures and patient safety,” Blike said.