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- Technologic Approaches 2
- Device-related Complications 1
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Search results for "Never Events"
- Legal and Policy Approaches
- Never Events
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.
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.
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 > Commentary
Clancy CM. Am J Med Qual. 2009;24:166-168.
This commentary describes the Centers for Medicare and Medicaid Services (CMS) nonpayment policy for never events and explores its potential impact on health care.
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.
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.
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.
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.
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.
O'Reilly KB. American Medical News. January 7, 2008.
This article discusses the evolving payer trend to withhold hospital reimbursement related to never events.
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.
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.
Journal Article > Review
Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.
Michaels RK, Makary MA, Dahab Y, et al. Ann Surg. 2007;245:526-532.
Wrong site operations are rare and often occur when systems to prevent them fail. This study reviewed existing prevention strategies, such as the Joint Commission's Universal Protocol, to develop a framework for hospitals to assess their wrong site event prevention efforts. The proposed framework asks whether a behaviorally specific policy has been enacted and whether staff understand the policy, and goes on to recommend directly observing the policy being put into practice. The authors advocate standardized interventions utilizing effective methods to measure safety. A previous Agency for Healthcare Research and Quality (AHRQ) WebM&M commentary discusses factors that place patients at risk for wrong site surgery.
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.
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
Bathla S, Chadwick M, Nevins EJ, Seward J. J Patient Saf. 2017 Jun 29; [Epub ahead of print].
Wrong-site surgery represents a never event. In the United States, The Joint Commission requires marking of the surgical site prior to surgery as part of the Universal Protocol. Researchers conducted a survey study of 120 surgeons in the United Kingdom and found significant variation in adherence to the national mandate for preoperative surgical site-marking.
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.
Youngberg BJ, ed. Sudbury, MA: Jones Bartlett; 2011. ISBN: 9780763774059.
This textbook discusses claims management, risk financing, and proactive risk reduction within the context of patient safety improvement.
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.