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- Specialization of Care 1
- Transparency and Accountability 1
- Identification Errors 1
- Medical Complications
- Medication Safety 1
- Surgical Complications 4
Search results for "Never Events"
- Never Events
- Patient Falls
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.
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.
Web Resource > Government Resource
Washington State Department of Health.
This Web site provides never event data to promote transparency and informed consumer decision making.
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.
Patient Safety Primers
Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.
Journal Article > Commentary
Growdon ME, Shorr RI, Inouye SK. JAMA Intern Med. 2017;177:759-760.
This commentary discusses unintended consequences of the well-intentioned strategy of keeping older adults in bed while hospitalized to reduce falls, a never event. The authors suggest that immobilizing patients is not the answer to fall prevention and advocate for hospitals to promote patient mobility as a routine part of care.
Journal Article > Review
Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Ann Intern Med. 2013;158(5 Pt 2):390-396.
Considered a never event for hospitalized patients, falls that result in serious injury remain relatively common despite increased attention to the issue. This systematic review identified approaches used to successfully implement fall prevention programs and found high-quality evidence that multicomponent interventions—including patient education, discontinuation of harmful medications, and wristband alerts—can significantly reduce inpatient fall rates. Although concerns have been raised that fall prevention programs could have unintended consequences, this review found that potential harms (such as increased use of sedating medications) had not been systematically evaluated. This review was conducted as part of the AHRQ Making Health Care Safer II report, and on the strength of this evidence, fall prevention strategies are considered one of the top ten patient safety strategies ready for implementation now. An institutional approach to fall prevention is discussed in an AHRQ WebM&M perspective.