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- Communication Improvement 1
- Education and Training 1
Error Reporting and Analysis
- Never Events
- Error Reporting
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Quality Improvement Strategies 2
- Specialization of Care 1
Search results for "Never Events"
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.
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
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.