The Tale of The Flying Gurney, and Other Events That Should Never Happen, But Still Do

John Palmer

While hospitals do their best to limit the number of so-called “never events” that happen to their patients, recent events show that there is still work to be done.

In patient safety circles, “never events” are mistakes that should simply never happen—seemingly commonsense mistakes such as a surgeon accidentally leaving a scalpel inside a patient, a newborn infant given to the wrong parents, or any death of a patient due to the gross negligence of a caregiver. When they do occur, it’s a big deal. The Leapfrog Group defines a never events as “adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability.”

A 2012 study reported there may be as many as 1,500 instances of one never event, the retained foreign object, per year in the United States. The same study suggests an estimated total number of surgical mistakes at just over 4,000 per year in the United States.

The flying gurney

An MRI is supposed to be a relatively easy and commonplace diagnostic test in a hospital, and certainly the danger of being flung into a high-power magnet should not be a concern to the patient. But that’s apparently exactly what happened in a Boston hospital.

It happened in February 2017 at Brigham and Women’s Hospital, when a patient undergoing an MRI for excruciating back pain was moved to a metal gurney in the hallway—and then for some reason a technician wheeled the gurney back into the MRI room—a big no-no. As anyone who experimented with magnets, metal objects are attracted by huge magnets like the one in an MRI machine.

According to a report in the Boston Globe about the incident, the MRI’s magnet began to drag the bed toward it with the patient still on it. Three staff members rushed to hold back the bed, but were not strong enough to fight the magnet’s power. They were forced to help the patient off the bed and let it fly into the room. The story described the sound inside the room as like a car crash as the metal bed was crushed. The bed was left there for three days, because an MRI magnet cannot be turned off right away; it needs to be powered down over a period of time to prevent damage to the machine.

Thankfully, no one was hurt. However, MRIs more commonly can turn common metal objects like hammers, oxygen tanks, and floor polishers into missiles, and even more commonly cause burns and hearing damage.

Perhaps most concerning is that these accidents are often difficult or impossible to track, because no national organization or agency collects reliable data on MRI injuries and near-accidents, the Globe article said.

Even Massachusetts, which requires hospitals and surgery centers to report deaths and serious injuries caused by metal objects in MRIs, does not track what are called “near-misses” such as the gurney incident. Between 2012, when the rules went into effect, and 2015, hospitals reported four injuries, the Globe reported.

These types of incidents are often kept private, due to embarrassment, making it difficult for health care providers to learn from one another’s mistakes, such as an incident in 2001, when a 6-year-old was killed at Westchester Medical Center in New York when an MRI turned an oxygen canister into a missile, which struck and killed the boy. But it happens much more than it should.

“This absolutely happens elsewhere, but people won’t talk about it,’’ Frank Shellock, a longtime MRI safety specialist affiliated with the University of Southern California, told the Globe. “There is no good source of information.’’

Alarming situation

Alarm fatigue has long been a hazard among healthcare facilities. With so many alarms going off around them on any given shift, you’d almost be tempted to forgive a hard-worked nurse for ignoring one or two of them. But all it takes is one mistake to make it fatal and lead to litigation.

NBC News reported in January that Kaiser Permanente San Francisco Medical Center is undergoing criminal investigation following the death of an 86-year-old patient in late 2015.

According to the report, authorities are investigating whether a nurse committed a crime when she silenced an alarm on a medical device connected to the elderly patient.

An investigation by the California Department of Public Health concluded the patient was in the intensive care unit undergoing treatment for kidney failure when a dialysis tube pumping blood back into his body came loose, which triggered an alarm on the device. The report says the patient’s family members were in the room at the time of the incident and state investigators a nurse silenced the alarm without checking the dialysis tube and then left the room. Later, the nurse returned to the room a short time later and pulled back a blanket covering the patient, a pool of blood had formed and the tube from the dialysis machine had become disconnected, according to the patient’s family members. The patient died two days later, according to the report.

The NBC News report further says the California Department of Public Health fined Kaiser $58,700 for the incident, as well as reporting the incident as law requires.  In addition, the report says investigation found that Kaiser threw away evidence, including the patient’s dialysis tubes.

Alarm fatigue, or the tendency of healthcare workers to be so inundated by a cacophony of alarms on patient units, has become such a problem that the Joint Commission in June 2013 released standard NPSG.06.01.01 as a new 2014 National Patient Safety Goal. The final standard included two phases: Phase I, beginning January 2014, required hospital leaders to “establish alarm system safety as a [critical access] hospital priority” by July 1, 2014. Phase II, which began January 1, 2016, requires hospitals to “educate staff and licensed independent practitioners about the purpose of proper operation of alarm systems for which they are responsible.”

Some hospitals have battled alarm fatigue with some encouraging results. In 2012, Boston Medical Center started a hospital-wide initiative that reduced alarms on all medical-surgical units from 1 million to 400,000 per week, a reduction of about 89% that positioned the hospital as a national model for reducing alarm fatigue-a recent hot topic in the patient safety world.

The results of the pilot program were published online in the Journal of Cardiovascular Nursing, showed a reduction in total mean weekly audible alarms by dropping averages from 12,546 per day to 1,424. Weekly alarms averaged 87,823 but dropped to 9,967 during the pilot. The most significant decrease came from changes for bradycardia, tachycardia, and heart rate parameter limits, which started at 62,793 per week and dropped to 3,970 per week.

What’s more, the decibel level on the floor dropped from 90 decibels to 72 decibels, the equivalent of noise levels generated by heavy traffic to normal conversation. Much of the success of the program was a result of changing default settings on device alarms, and did not require investment in new technology or staff.

Active shooters and violence

Although shootings aren’t listed in the official definition of a never event, patient deaths and injuries suffered from them can nevertheless fall under the category of harm caused by assaults in a healthcare facility.

So what’s the chance you or your staff are going to have to deal with an active shooter? Well, it depends. Your location, types of patients, community, and many other factors determine your facility’s risk. The statistics, however, are sobering. According to some estimates, nine shootings took place during the time period of 2000-2006, and from 2006-2015 the number almost doubled to 16 shootings a year. Of those, some 30% happen in hospital emergency departments. Some security experts say it’s only a matter of time before active shootings become something that occurs in hospitals.

“Every individual believes that acts of violence, such as active shooter events in healthcare facilities, will never happen to them or those they love,” writes Lisa Terry, CHPA, CPP, in the HCPro book, The Active Shooter Response Toolkit for Healthcare Workers. “Active shooters in hospitals are inconceivable in our normal realm of thinking and everyday lives. Acts of violence are often referred to as ‘never events’ in the security industry – since they should never happen and are avoidable if we are effectively prepared to identify and mitigate risks of occurrence. The increased number of active shooter incidents in today’s environment is a deadly reminder that ‘never events’ not only can happen – they DO happen!”

Like any other sound plan, you can’t know what you need to plan for if you don’t know the risks involved. That’s why it’s a Joint Commission and CMS requirement to do what’s called a “Hazard Vulnerability Assessment,” or HVA. It identifies every potential threat to your facility, from storms, earthquakes, chemical spills—and violent incidents.

You should know this already, but what are the threats in your community and your population that could increase the risk of an active shooter? More often than not, healthcare workers complain that they don’t feel they are well-trained to respond to a violent attack. It’s time to change that. At the very least, hospital staff need to learn how to recognize and then de-escalate a potentially violent situation.

Take lessons from Minnesota

Minnesota hospitals have earned the reputation of having some of the safest hospitals in terms of adverse patient safety events, but at a cost.

In the early 2000s, the became the first state requiring its hospitals and ASCs to publicly submit annual reports about adverse events affecting patient safety.

A decade later in 2014, a 10-year program evaluation by the Minnesota Department of Health showed the number of reported adverse events was at its lowest since the program was started,

Still, in the same report, several Minnesota medical centers came under fire in 2013 following a rise in the number of preventable deaths and serious disabilities among patients, including suicides. The uptick in such events triggered state interventions that required staff retraining and increased scrutiny on how facilities were keeping patients safe. The Adverse Health Events in Minnesota report, released by the Minnesota Department of Health in January 2013, detailed the number of patient deaths and injuries that occurred in state hospitals and surgery centers during a one-year period ending in October 2012. At least 26 states have followed Minnesota’s lead by tracking and reporting adverse events-things that are not supposed to happen in hospitals, such as patient suicides, disappearances, and medical errors (e.g., leaving items in patients during surgery).

Hospitals looking to make their facilities safer for their patients can take a lesson from their colleagues in Minnesota, but safety experts everywhere have already begun looking at ways to improve security, from training to almost-invisible “soft changes” in the environment.

“It’s a challenge to make it look warm and inviting and safe, but you don’t want to make it look like a prison, but patients find things to hurt themselves,” says Chris Walker, MSN, RN, MHA, director of inpatient mental health units and behavioral access nurses at St. Cloud (Minn.) Hospital. “Some patients have visitors that will sneak in pills and drugs, and some will find something like a paper clip on the floor to try to injure themselves.”

Here are some ways a facility can improve the safety of both staff and patients:

Lower surfaces. Although it can be pricey and difficult for older hospitals to renovate current spaces, newer construction is focusing on design elements that provide fewer opportunities for patients to harm themselves. “You want to design it in such a way that it makes it difficult to jump off higher areas,” says Thomas A. Smith, CHPA, CPP, president of Healthcare Security Consultants, Inc., in Chapel Hill, N.C. Smith has served on a task force for construction and renovation for the International Association for Hospital Safety and Security, which focuses on recommendations ranging from avoiding high parking decks to rooftop play areas (a hospital in North Carolina tried it).

Search everyone. Especially in a busy emergency room environment, it can be difficult to assess who will be a violence or a suicide risk, so many hospitals have developed procedures for screening patients as they are admitted. Clothes are removed; sharps, belts, and jewelry are inventoried; and purses and other belongings are placed somewhere safe. In the meantime, a nurse or other staff member asks some basic questions to ascertain each patient’s baseline mental status. Finally, a patient may be given a color-coded set of scrubs to dress in.

Make a list, check it twice. Many physicians and hospitals swear by checklists to minimize mistakes in the surgical suite. Perhaps not surprisingly, the airline industry has become one of the safest industries partly because of a reliance on checklists and redundancies. Now, some hospitals are adapting checklists to other areas, such as the behavioral care unit.

St. Cloud Hospital uses a checklist that gives staff a list of things to do when preparing a room for a new patient arrival. Tasks on the checklist include things like moving extra garbage cans into the bathroom, removing excess furniture and cords, taking down decorative crucifixes, and folding a room’s computer up into a wall when it’s not being used.


John Palmer is a contributing writer to PSQH.