Seeing the Rose Garden superspreader convocation as a ‘never event’

President Donald Trump’s surprisingly rapid discharge from Walter Reed National Military Medical Center, coupled with conflicting and vague statements on his condition, has created a whirlwind of confusion among the public. There’s a lot we don’t know, such as how he was exposed to SARS-CoV-2, the virus that causes Covid-19, what kind of treatments he may still be receiving, and how effective they may be.

But there is one thing we do know: His infection was absolutely preventable.

In health care, the term “never event” refers to a serious, preventable occurrence that could have severe implications for a patient. These are normally things like operating on the wrong knee, giving the wrong medication, or discharging an infant to the wrong person.

In these far-from-normal times, we can now add to that list of examples the growing outbreak of Covid-19 in Washington, D.C., where the president, First Lady, members of Congress, the White House press secretary and other staff members, members of the media, and countless employees who support the operations of the U.S. government and the Trump reelection campaign were infected by the coronavirus.

Many point to the September 26 gathering in the White House Rose Garden to announce the nomination of Amy Coney Barrett to the Supreme Court as a potential “superspreader” event. Crowds of people were in close proximity, shaking hands and hugging. Many were not wearing masks.

Why frame the outbreak as a never event? Because it meets all the criteria that the National Quality Forum uses to define one, and thinking of it that way points toward changes we can make to keep such contagion from happening in other settings. It was serious because of the potential impact of Covid-19, especially in older individuals and those with pre-existing conditions. It was preventable because strategies to reduce the risk of infection — such as mask wearing and social distancing — are known and have been disseminated by the Centers for Disease Control and Prevention, an agency of the U.S. government, yet were widely ignored. It was of concern because the hospitalization of the president and the broader impact on our government resulting from this outbreak posed a threat to our national security.

Never events are opportunities for learning. When they happen in the health care setting, the care team and health system leadership should do a careful analysis of what happened, why it happened, and what can be done to ensure it never happens again. The focus begins on the system in which care is delivered — not on individuals working in that system — because most errors are the result of flawed systems. That said, failing to follow policies and procedures in well-designed systems can also lead to adverse events. Never events represent an open invitation to those in health care to speak candidly, regardless of who might be offended, about how things could and should be different.

What we know so far is that despite CDC recommendations about the use of masks and physical distancing, events held at the White House and on behalf of the president’s reelection effort disregarded the guidance. Use of masks was cast as a “personal choice.” A significant number of attendees at the Rose Garden gathering did not wear masks, and a number of them have now tested positive for Covid-19. The White House grounds are tightly controlled: Who comes, who goes, where they go when they are there, and what conditions they have to meet to gain access are entirely within the control of White House administrative leadership.

The White House Medical Office and administrative team have an obligation to ensure that the risk of Covid-19 infection to the president, his family, and his staff is as low as possible. Medical science gave them a variety of tools to do that — including wearing masks and social distancing — the same ones the CDC recommends for keeping the rest of us safe. It appears that the failure occurred because clear medical science, including the advice of federal agencies, was disregarded, not just at the White House but in a variety of settings in which the president appeared.

What does this mean for the rest of the country? We are in the midst of a national political debate, with the president at the center, about our willingness to collectively adopt proven strategies that reduce the risk that any of us is infected with SARS-CoV-2. The president himself has expressed skepticism about the seriousness of the disease and has declined to follow evidence-based medical advice with respect to his own appearances. Following medical guidance is viewed by many as a choice that infringes personal freedom.

The President’s illness can and should be a wake-up call to even the most ardent skeptics that this is a serious disease and can affect any of us. We disregard medical science at our individual and collective peril.

It is also a wake-up call to physicians everywhere that they must be careful not to allow their voices to be silenced because of operational, financial, or political considerations. At this time of national uncertainty, physician voices clearly informed by the best science are essential for our ability to survive and thrive as a society. Silence undermines our fundamental commitment to our patients and the public good.