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- Error Reporting and Analysis
- Legal and Policy Approaches 13
- Quality Improvement Strategies 4
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- Medical Complications 13
- Medication Safety 2
- Psychological and Social Complications 2
- Surgical Complications 9
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Journal Article > Commentary
West JC. J Healthc Risk Manag. 2006;26:15-21.
The author compares surgical event data from the first Minnesota state report on medical error with published research on similar incidents. He concludes that, because adverse events occur infrequently in individual institutions, large-scale databases are needed to aggregate data for study.
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
The National Quality Forum originally defined 27 health care "never events"—patient safety events that pose serious harm to patients, but should be considered preventable—in 2002. The 2011 update now consists of 29 events, organized into surgical events (e.g., wrong-site surgery), device events (e.g., air embolism), care management events (e.g., death or disability due to medication errors), patient protection events (e.g., patient suicide), environmental events (e.g., fires), radiologic events, and criminal events. One notable addition to the original list is that serious harm associated with failure to properly follow up on test results is now considered a never event. Since the development and dissemination of this list, many states have mandated that health care facilities report all instances of these events. When such an event occurs, many institutions mandate performance of a root cause analysis.
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.
O'Reilly KB. American Medical News. January 7, 2008.
This article discusses the evolving payer trend to withhold hospital reimbursement related to 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.
NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.
DerGurahian J. Mod Healthc. June 16, 2008;38:6.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.
The Tax Relief and Health Care Act of 2006 mandated that the Office of Inspector General (OIG) report to Congress the incidence of "never events" among Medicare beneficiaries, payment by Medicare for services in connection with such events, and the process used to identify events and deny payments. This report addresses that mandate by providing a descriptive analysis of the key issues to understanding hospital-based adverse events. The report is focused around discussion of seven critical issues that are explored in detail. Of note, OIG expanded the study of never events to the broader topic of adverse events in their analysis.
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.
Journal Article > Commentary
Milstein A. N Engl J Med. 2009;360:2388-2390.
Never events represent a list of adverse events that are serious, unambiguous, and usually preventable. The National Quality Forum defined 28 never events in a 2007 consensus report that led to state mandates for reporting and financial implications for payment of services. This commentary discusses the context of these policy implications and how they are a small step toward motivating hospitals and clinicians to improve quality and safety.
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.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
This brief provides information on 101 sentinel events reported to the state of Utah in 2009. The report also includes background on efforts to address such incidents.
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.
Shreve J, van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. Schaumburg, IL: The Society of Actuaries; 2010.
Although the Institute of Medicine's estimate of up to 98,000 deaths yearly from preventable adverse events has become part of popular parlance, in truth, the true burden of medical errors remains controversial. This case–control study analyzed a large claims database of more than 24 million patients to identify errors, deaths, and costs, and found that more than 1.5 million preventable adverse events occur in hospitalized patients yearly, resulting in $19.5 billion in excess costs and 2500 excess deaths yearly. The most common preventable errors were pressure ulcers—considered a never event—and health care–associated infections. By comparing the outcomes of patients who experienced an error to patients with similar illnesses who were not harmed, this study was able to estimate costs and mortality directly attributable to errors. Prior research has found that administrative data may underestimate error incidence, so the true number and impact of errors may be higher than that reported here. Nonetheless, this study represents a significant step forward in defining the epidemiology of error in hospitalized patients.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.
Hospitalized patients continue to suffer iatrogenic harm, according to this study of Medicare patients completed by the Office of the Inspector General (OIG). Using methodology similar to the landmark Harvard Medical Practice Study, this study found that 13.5% of hospitalized Medicare patients experienced an adverse event, of which nearly half were considered preventable. However, fewer than 2% of patients experienced either a never event or a preventable complication for which hospitals are no longer reimbursed by the Centers for Medicare and Medicaid Services. These results are similar to the OIG's prior 2008 report. Based on these results, OIG recommends further efforts to accurately measure adverse events, and also recommends broadening the "no pay for errors" policy. The challenges of accurately measuring safety problems are discussed in an AHRQ WebM&M commentary.
Washington, DC: National Quality Forum; June 13, 2011.
This publication announces the 2011 National Quality Forum update of 2010 never events. The opportunity to provide open comment of the 29 serious reportable events, which includes 4 new events, has now passed.
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.