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(Never Say) Never Events in Radiology

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Is it time to reassess what constitutes a never event?

At some point in the murky past of my health-care career, I encountered the term “never event.” It wasn’t presented to me as new terminology, but the context made it clear: Whatever it was, it should never happen.

I liked that. It sounded strong and decisive. Here is something bad, and we are making sure that it is never going to happen. So much of health care is wishy-washy and uncertain. Using absolutes like “never” is a rare treat. I don’t know how much “cannot rule out” hedging I had encountered at that point, but it felt like more than enough.

I am older and wiser now, or at least more cynical. I have come to see that you can proclaim events as “never” as you want, but they are going to happen. If you look for definitions of “never events,” examples commonly include surgery performed on the wrong body part or the wrong patient. Guess what still happens? Thank heaven, it’s very uncommon, but “rare” does not equal “never.”

Along the way, I adopted the term for my own use. If something bad and preventable occurred, especially in a way that ticked me off and inspired me to talk to a supervisor or other in-charge type, I might just proclaim it a never event. I am not one for mindlessly adopting jargon, but if it tickles their neurons in the way necessary to get a proper reaction, I will do it.

Reading a whole-body cancer follow-up scan without priors because they’re “unobtainable” only to receive the priors the next day with a demand for addendum, for instance, is nowhere near as bad as amputating the wrong limb, but it is still an easily avoided bad practice. It should also “never” occur that a study gets performed and placed on a rad’s worklist without a clinical history. (I would go so far as to specify a billable history; “r/o pain” should encounter an impenetrable roadblock.)

It doesn’t matter who is using the term though. “Never” is a never event in and of itself. About the only way you can really concoct a never event is if you intentionally dream up something that cannot possibly happen. I could say it is a never event for my nuclear medicine practice to erroneously administer plutonium to a patient, for instance, but would that really accomplish anything when we never have plutonium in the first place?

That in mind, the term “never event” sort of goes limp, like when too many people started saying “literally” for emphasis rather than its actual meaning. (I will never forgive dictionaries for rolling over and amending their definitions to support that by the way.) “Never” winds up being a vague threat that when (not if) it happens, the event will be scrutinized after the fact. There will be an emphasis on assigning blame to existing policies, if not individuals. This will beget new policies that may or may not prevent another instance but will definitely bog down all related protocols.

Consider the following case in point. Pre-procedural “time-outs” to ensure that everything is as it should be, and what is about to be done are desired. I’m sure adopting these time-outs on a large scale has averted some badness. How could it not? But don’t tell me that badness never occurs anymore because of it. The best that can be said is that these time-outs have moved the needle in the direction of (unachievable) never. How much does that needle need to move to justify the added time and reduced efficiency of all procedures pausing for a time-out? Go ask a philosopher.

I have noticed something about never events, and the thinking behind them. You don’t really hear the rank-and-file talk in such terms. They know what they are supposed to do, of course, and if you asked them to rank a bunch of undesired outcomes in order of severity, they would have no problem placing typical never events above others. However, they would also be able to rattle off multiple imperfections in the complex-system health-care machine they inhabit and ways that those imperfections could line up to allow terrible things, including never events, to occur.

Meanwhile, folks a step or three up the food chain do use such terms, often wielding them as evidence of their loftier positions. With these folks sitting in committees and removed from the daily grind of getting the actual work of patient care done, it is easier for them to lose sight of the multiple flaws that could align to produce mayhem.

Insulated as they are, they might very well believe that “never” is achievable. Alternatively, they might know they had darned well better pretend that they believe such things, since admitting any less could torpedo their chances at moving further up the ladder, or even undermine their current standing.

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