Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 1
- Education and Training 3
- Error Reporting and Analysis
- Human Factors Engineering 2
- Legal and Policy Approaches 12
- Logistical Approaches 1
- Quality Improvement Strategies 7
- Specialization of Care 1
- Transparency and Accountability 1
- Device-related Complications 1
- Identification Errors 5
- Medical Complications
- Medication Safety 3
- Psychological and Social Complications 1
- Surgical Complications 15
- Transfusion Complications 2
- Australia and New Zealand 1
- Europe 2
- North America 29
Search results for ""
Patient Safety Primers
Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Lerner M. Star Tribune. September 18, 2007;News section:5B.
This article reports on Minnesota's adoption of a policy for hospitals to not charge patients or insurers for never events or consequent treatment.
Kowalczyk L. Boston Globe. September 17, 2007;Metro section:1A.
This article reports on how numerous Massachusetts hospitals have implemented policies to waive charges for the set of serious errors categorized as never events.
Ostrom CM. Seattle Times. January 29, 2008;News section:A1.
This article discusses a voluntary initiative in the state of Washington to cease billing patients for costs associated with preventable errors.
More states shred bills for awful medical errors: patients in 23 states will no longer pay for certain mistakes, hospitals say.
Aleccia J. MSNBC News. August 12, 2008.
This article reports on the implementation and expansion of several states' non-payment policies for medical mistakes in light of similar policies set by Medicare and private insurance companies.
May H. Salt Lake Tribune. August 18, 2008.
This article examines 2007 state health data on never events in the context of a label-related medical error that resulted in a recent death.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220.
The Center for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for the costs associated with certain preventable adverse events, many (but not all) of which are considered never events. This report from the federal Office of the Inspector General (OIG) examines the adverse events in a sample of Medicare beneficiaries. As outlined in a previous report, the OIG chose to evaluate the overall incidence of adverse events, including "no pay for errors" conditions, never events, and all other adverse consequences of hospitalization, including non-preventable adverse events. Therefore, the 15% overall incidence of adverse events found in this study should be interpreted with caution. Less than 1% of patients experienced a never event, and approximately 4% experienced a condition on CMS's no pay for errors list.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
This report from the United Kingdom is intended to guide Primary Care Trusts in implementing never events policies for 2009-2010.
Journal Article > Commentary
The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits.
Streiff MB, Haut ER. JAMA. 2009;301:1063-1065.
This commentary addresses the Centers for Medicare and Medicaid Services' classification of venous thromboembolism as a never event.
Bunting RF Jr, Schukman J, Wong WB. Washington, DC: Atlantic Information Services, Inc.; 2009. ISBN: 1933801557.
This biannually updated publication and companion CD provide detailed health care risk management strategies and tools to reduce adverse events.
Journal Article > Study
McNair PD, Luft HS, Bindman AB. Health Aff (Millwood). 2009;28:1485-1493.
A 2008 policy change by the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for some preventable errors, including certain never events and hospital-acquired infections. This policy has catalyzed efforts to realign payment incentives and patient safety efforts, despite the fact that, as this article demonstrates, the actual financial effects of the policy are likely minimal. Based on California hospital discharge data, the authors estimate that the total nationwide Medicare payment reductions would amount to only $1.1 million yearly. The authors suggest several methods for strengthening the policy, including denying payments for readmissions associated with hospital-acquired complications. The implications of the CMS "no pay for errors" policy are further discussed in an AHRQ WebM&M perspective.
Journal Article > Study
Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.
The term never event was originally coined to describe rare, devastating, and preventable events like wrong-site surgery or fatal medication errors. This definition has expanded over time to include a variety of serious adverse events; for some of them (i.e., certain health care–associated infections), the Centers for Medicare and Medicaid Services denies additional reimbursement. This article sought to determine if eight never events (mostly infectious complications of surgery) are truly preventable, by examining whether baseline patient characteristics could predict which patients would experience a never event. The authors found that incidence of most of these complications could be predicted on the basis of preexisting conditions or the specific surgical procedure performed, calling into question whether these events are truly preventable. This study exemplifies research into the "basic science" of patient safety; a prior commentary called for studies focusing on identifying truly preventable harm and developing accurate, reliable measurement standards.
Journal Article > Study
Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.
Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010;25:1097-1101.
A 2008 policy change by the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for certain preventable errors, including selected never events and hospital-acquired infections. The impact of the policy was debated, including the ability of providers and systems to accurately identify conditions present on admission. This study involved an educational intervention to assess the policy's impact on clinical practice among trainees. In a series of presented clinical vignettes, members of the intervention group, who received education about the new policy as part of the study, were less likely than participants who received no such education to select the most clinically appropriate response. While all the trainees acknowledged responsibility to understand CMS documentation rules and felt poorly trained to do so, their responses to the vignettes raised concern about the potential harm and unintended consequences caused by unnecessary testing and procedures that may result from the policy. The implications of the CMS policy are further discussed in an AHRQ WebM&M perspective.
Washington DC: National Quality Forum; 2010.
The landmark Institute of Medicine (IOM) report, To Err Is Human, called for states to publicly report never events—medical errors that resulted in death or severe disability. This National Quality Forum publication evaluates the current status of state reporting systems 10 years after the IOM report, and summarizes the strengths and limitations of current public reporting initiatives. To date, 28 states maintain some type of reporting system, primarily tracking never events and health care–associated infections. However, states vary significantly in their implementation of these systems, requirements for reporting errors, and regulations regarding analysis and follow-up of errors, limiting the effect of reporting systems on improving patient safety. An AHRQ WebM&M perspective discusses the challenges and opportunities faced by current state reporting systems.
Journal Article > Study
Thorson CM, Ryan ML, Van Haren RM, et al. Crit Care Med. 2012;40:2967-2973.
A subset of trauma patients had a relatively high risk of postoperative venous thromboembolism despite use of appropriate prophylactic measures, calling into question the "wisdom and justice" of classifying this complication as entirely preventable.
Journal Article > Review
Sullivan N, Schoelles KM. Ann Intern Med. 2013;158(5 Pt 2):410-416.
As the patient safety evidence base matures, the focus is shifting from effectiveness (identifying which strategies can prevent errors) to implementation (ensuring that all patients receive effective strategies). Pressure ulcers are considered a never event, but their incidence has been increasing despite effective preventive strategies. This systematic review identifies several promising methods of implementing multicomponent interventions to prevent pressure ulcers and emphasizes the importance of leadership, simplification and standardization of safety strategies, and regular audit and feedback of pressure ulcer rates in ensuring intervention success. This study was funded by the Agency for Healthcare Research and Quality as part of the Making Health Care Safer II report and was published as part of a special patient safety supplement in the Annals of Internal Medicine.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.