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- Never Events
Journal Article > Study
Smith S, Snyder A, McMahon LF Jr, Petersen L, Meddings J. Health Aff (Millwood). 2018;37:1787-1796.
Hospital-acquired pressure ulcers (HAPUs) are considered a never event, represent a significant source of patient harm, and can result in loss of payment to hospitals. In this study, researchers analyzed administrative data from 3 states for 2009 to 2014. The HAPU incidence they found was about one-twentieth of the HAPU incidence detected using chart review. In addition, while both chart review data and administrative data showed a reduction in HAPU incidence for the study period, the decline using administrative data was almost entirely due to a decrease in the incidence of lower stage pressure ulcers. The authors suggest that using clinical data from chart review and taking ulcer severity into account may yield a more meaningful measurement strategy.
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 > 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.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
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.
Carpenter D. Hosp Health Netw. November 2007;81:34-38.
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.