Narrow Results Clear All
- Communication Improvement 1
- Education and Training 2
- Error Reporting and Analysis
- Human Factors Engineering 1
- Legal and Policy Approaches 3
- Quality Improvement Strategies 3
- Specialization of Care 1
Search results for ""
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.
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.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Journal Article > Study
Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. Health Aff (Millwood). 2011;30:596-603.
The Centers for Medicare and Medicaid Services stopped reimbursing hospitals for additional costs associated with certain preventable adverse events in 2008. Despite the widespread controversy engendered by this policy, the actual financial effect has been small, leading to calls for expansion of the policy. This actuarial study used a case-control approach to estimate the annual marginal cost of preventable adverse events in hospitalized patients at $17.1 billion, largely attributable to post-surgical complications, health care–associated infections, and pressure ulcers. Never events accounted for approximately $3.7 billion in excess costs. The results of this study provide targets for policy efforts to control health care costs and improve patient safety.
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-0006-EF.
Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.
National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer.
Rockville, MD: Agency for Healthcare Research and Quality; December 2016.
Medicare nonpayment and reporting requirements have stimulated health care organizations to focus on reducing hospital-acquired conditions (HACs) such as health care–associated infections and never events. The Agency for Healthcare Research and Quality regularly tracks HAC rates, including rates of adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, falls, obstetric adverse events, pressure ulcers, surgical site infections, ventilator-associated pneumonias, and postoperative venous thromboembolisms. According to data from the AHRQ National Scorecard, HACs have decreased by 21% between 2010 and 2015. This represents a total of 3.1 million fewer HACs contracted by hospitalized patients over 5 years, saving an estimated 125,000 lives and $28 billion. These findings represent substantial progress and support the success of incentives designed to eliminate HACs as a source of patient harm.