When Is a 'Never Should Occur' a 'Never Event': Or Do We Really Need a Burning Platform?

摘要

The article by Chang et al in this issue ("Evaluating Metrics for Quality: Death on the Same Day of Elective Pediatric Surgery") is a provocative work on many fronts. First, it demonstrates the growing use of large (>800 000 pediatric admissions), easily accessible administrative databases with the goal to identify and hopefully spark improved clinical quality. Second, the study provides an incidence of a clinical event that has not yet received a significant amount of national focus despite representing a parent's nightmare: their child dying after being handed over to a care team for "elective" surgery. Finally, it brings up the provocative question of what to do with the data.