Straight Talk Tuesday

I recently attended the American Professional Wound Care Association meeting where Kevin Yankowsky of Norton, Rose, Fulbright, talked about the criminalization of adverse events including pressure ulcers. The National Quality Forum lists Stage 3 and 4 pressure ulcers on its website as serious, preventable adverse events. http://www.qualityforum.org/Publications/2007/03/Serious_Reportable_Events_in_Healthcare%E2%80%932006_Update.aspx.

I will quote here, “NQF expects that any of the 28 serious reportable events that occur will be investigated for cause or contributing factors and the findings acted upon to prevent future occurrences. Each individual incident [italics mine] should be reported, not frequencies of events.” Stage 3 and 4 pressure ulcers are under the section called “Care Management Events.” What other events are in that section? I won’t list them all but here are a few examples: Patient death or serious disability associated with a medication error (wrong drug, wrong dose, wrong patient, etc.); Patient death or serious disability associated with a hemolytic reaction due to the administration of incompatible blood products; and Artificial insemination with the wrong donor sperm or wrong egg. You will be relieved to know that Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility are EXCLUDED from mandatory adverse event reporting if they “progressed from Stage 2 to Stage 3 and the Stage 2 was recognized upon admission.” Wow. I feel so much better.

I just want everyone to be clear on what the NQF says. The premier safety organization in the USA thinks that: 1) All stage 3 and 4 pressure ulcers represent a failure of care, 2) Stage 3 pressure ulcers progress from Stage 2 pressure ulcers and 3) Stage 3 and 4 pressure ulcers are serious reportable events that are (always) preventable. The fact that all 3 of these assertions are wrong would not be so scary if it were not that there are people now in jail on criminal charges relating to pressure ulcer formation. It’s not that pressure ulcers are NEVER the result of negligence; it’s just that they are not ALWAYS the result of negligence. And once again, confusion over the staging system is contributing to the problem.