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“Never Events” in Cardiac Surgery: Serious Reportable Events Continue to Occur in Our Patients
*Michael P Robich1, Alik Farber2, Reed Quinn1, *Denis Rybin2, *Douglas Sawyer1, *Gheorghe Doros2, Robert Kramer1, *Jeffrey J Siracuse2
1Maine Medical Center, Portland, ME;2Boston Medical Center, Boston, MA
Objective: “Never events”(NE) are preventable adverse events that occur in the hospital. We sought to understand the occurrence of serious reportable events in patients undergoing cardiac operations.
Design: Retrospective review, Nationwide Inpatient Sample, 2003-2011
Setting: Hospitals in the US
Patients: 588,417 adult patients undergoing isolated primary coronary artery bypass grafting (CABG)(398,816), valve (181,066), and thoracic aortic operations (8,535).
Main Outcome Measures: Never events
Results: There were 4377 NE (0.7%). The rate of NE increased from 0.5% in 2003 to 1.1% in 2011, P<.001. In 2008, CMS announced they would no longer reimburse NE, but the risk of NE increased (OR 1.7 after 2008 [(95% Confidence interval) 1.6-1.8] Falls/trauma were most common (42%) followed by vascular catheter infections (15%), complications of poor glucose control (14%), mediastinitis (13%), UTI (10%), advanced pressure ulcer (5%), retained foreign body (4%), air embolism (0.9%), and blood incompatibility (.02%).
On multivariate analysis risk factors included aortic (OR 2.5 [1.9-3.2]) and valve (1.3 [1.1-1.4]) operations vs. CABG, non-elective (2.4 [2.1-2.7]) and weekend admissions (1.3 [1.1-1.4]). Female sex (1.3 [1.2- 1.5]), metastatic cancer (2.3 [1.1-5]), diabetes (1.5 [1.3-1.8]), renal failure (1.5 [1.2- 1.8]), and CHF (1.4 [1.3-1.6]) were associated with increased risk of NE (P value for all <.001). Factors not associated with increased risk included admission July through September (P .7) and teaching hospital (P .09). Length of stay with NE was 21±19 days vs. 10±8 without (P<.001). Mortality was 8% with NE and 3% without (P<.001). Median charges with NE were $245,000±244,000 vs. $123,000±102,000 (P<.001).
Conclusions: The rate of serious reportable events after cardiac surgery was low, but increased over time. Understanding risk factors may help prevent these potentially avoidable complications.
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