“Never Events”

Dangerous situation on city roads

As previously reported, PeaceHealth St. Joseph Medical Center in Bellingham, Washington was found to be out of compliance regarding the use of restraints, seclusion, isolation, patient care and emergency services in an investigation by the Washington State Department of Health.

One critical issue that this investigation missed was the issue of elopement of a vulnerable adult who ran out of the hospital, barefoot and in scrubs, and was later found over 2 miles away.  This event is called a “Never Event” by the Patient Safety Network of the US Department of Health and Human Services.

Patient protection events
Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person
Patient death or serious disability associated with patient elopement (disappearance)
Patient suicide, attempted suicide, or self-harm resulting in serious disability, while being cared for in a health care facility

It is clear from the medical record, investigation, reports from local police and family/guardian that the hospital was well aware that this patient was a vulnerable adult under a guardianship yet when this person left the hospital and the hospital staff was well aware that he ran out of the exit while being escorted to the restroom,  the hospital did not notify anyone.  Does this hospital have a policy regarding missing patients such as a special code called?  That is the standard of care and apparently this hospital does not practice up to the standard of care.

I have contacted the DOH team which did this investigation asking questions why this critical event was missed and not addressed in the investigation.  I am still awaiting a response.

I am so thankful that the outcome was not what we see in the photo below – but given the circumstances, this was a real possibility by the “Never Event”

Body of a young child covered by a sheet“.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s