VA Never Events


Here’s a conundrum for a VA Hospital.

According to this article in the Oregonian, the widow of a patient who fell to his death from the roof of a Veterans Affairs Medical Center is suing the hospital and the doctors for $4.5 million.

The federal government has already stated that a patient death associated with a fall while being cared for in a healthcare facility is a “never event.”


I wonder whether the widow’s attorney will use the federal government’s new classifications of never events as proof that the government hospital was negligent. After all, if the government states, in effect, that such events should “never” happen, shouldn’t the occurrence of such an event be used as prima facie evidence of the government hospital’s negligence in this matter?

Strict liability.

Hello, summary judgment.



  1. I am confused. The ER doc did not order constant observation in someone who was suicidal? If it was documented that he WAS suicidal by the him , but then he was just sent to the floor, then there is probably some liabilty there. Also, did the psychiatrist see him in the ER? Often they are the ones who order CO’s.

  2. The article states that the family is suing OHSU although the death was at the VA. I don’t know if this is till the policy, but 10 years ago, vets/families of vets were not allowed to sue the VA unless they had been through arbitration first, which markedly reduced the number of suits brought against the VA. I am assuming that policy is still in effect and is the reason for suing OHSU.

  3. You’re rarely going to get an accurate distillation of hundreds of pages of records from a 200 word article. That said, OHSU is probably just named initially because it’s unclear who the employer of the physicians actually was. You often can’t get that information without suit being filed and a deposition.

  4. Probably this is not a problem. All VA hospitals are exempt from EMTALA (And yes, having worked at a hospital ER around the corner from the VA, VA hospitals ARE exempt from EMTALA). So it would seem logical that they are exempt from never events.

  5. But if it is a NEVER event, it didn’t happen, right?
    They are defining all kinds of things as ‘never happen’ –

    ….circling the rabbit hole

  6. Pingback: Hospital patient falls as “never events”

  7. The distinction between OHSU and the VA med center in Portland is somewhat blurred. They are in connected buildings, and the VA operates its emergency room ‘regular business hours only’. After-hours, emergencies are treated at the OHSU ER, and then, if needed, admitted from there directly into the VA hospital, so it is possible this man was admitted to the VA hospital through the OHSU ER by an OHSU ER doc, thus OHSU being named in the suit.

  8. Pingback: “Never Event” Occurs at VA Hospital | Linda Gorman | NCPA

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