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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.
Pear R. New York Times. August 19, 2007.
This article reports on a new Centers for Medicare and Medicaid Services (CMS) rule mandating that Medicare will no longer pay for treating certain preventable errors starting in 2008, including some hospital-acquired infections, decubitus ulcers, and retained foreign bodies. The policy is generating considerable discussion in patient safety circles, with some expressing concerns regarding the economic impact on hospitals and the increased efforts it is likely to create for hospitals to document certain patient problems present at the time of admission.
Lubell J. Modern Healthc. August 20, 2007;37:10.
This article discusses the challenges hospitals face in responding to recent Centers for Medicare and Medicaid Services (CMS) policy changes affecting reimbursement for eight hospital-acquired conditions.
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.
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.
O'Reilly KB. American Medical News. May 12, 2008.
This article reports that the Centers for Medicare and Medicaid Services (CMS) has proposed expanding the list of hospital-acquired conditions that it will no longer cover.
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.
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.
Legislation/Regulation > Government Resource
Medicaid program; payment adjustment for provider-preventable conditions including health care–acquired conditions.
Centers for Medicare & Medicaid Services. 42 CFR Parts 434, 438, and 447: June 1, 2011.
This final rule prohibits federal reimbursements to states for costs associated with health care–acquired conditions. The regulations are effective as of July 1, 2011.