Definition
Never Events are defined as adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability.
(Leapfrog Group )
Abbreviations used in this article
Abbr. | English | Chinese |
---|---|---|
NQF | National Quality Forum | 國家品質論壇 |
CMS | Centers for Medicare and Medicaid Services | 醫療保險和醫療補助服務 |
JCAHO | Joint Commission on Accreditation of Healthcare Organizations | 美國醫療機構評鑑聯合會 |
AHRQ | Agency for Healthcare Research and Quality | 醫療保健研究與品質機構 |
Background
The term Never Event
was first introduced in 2001 by Ken Kizer in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The list is grouped into six categorical events: surgical, product or device, patient protection, care management, environmental, and criminal.
Most Never Events are very rare. For example, a 2006 study estimated that a typical hospital might experience a case of wrong-site surgery once every 5 to 10 years. However, when Never Events occur, they are devastating to patients — 71% of events reported to JCAHO over the past 12 years were fatal — and may indicate a fundamental safety problem within an organization.
JCAHO has required that hospitals report sentinel events
since 1995. Sentinel events are defined as an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof.
The prohibited incidents
referred to by the National Quality Forum are also regarded as sentinel incidents by JCAHO.
Current Context
Because Never Events are devastating and preventable, health care organizations are under increasing pressure to eliminate them completely. In August 2007, CMS announced that Medicare would no longer pay for the treatment of many preventable errors, including those considered never events (non-reimbursable serious hospital-acquired conditions
).
- catheter-associated urinary tract infection
- vascular catheter-associated infection
- surgical site infection following coronary artery bypass graft (CABG) — mediastinitis
- surgical site infection following bariatric surgery (laparoscopic gastric bypass, gastroenterostomy, laproscopic gastric restrictive surgery)
- surgical site infection following orthopedic procedures (spine, neck, shoulder, elbow)
- deep vein thrombosis (DVT) / pulmonary embolism (PE) in total knee replacement and hip replacement
The growing trend of public reporting on health care quality has also focused on reporting Never Events as a means of increasing accountability and potentially improving the quality of care. While most on the list of serious reportable events
include obvious unacceptable errors, such as wrong site surgery or discharge of an infant to the wrong person, not all events are preventable at all times or indicative of obvious negligence.
A goal of quality improvement should be to institute a reduction of never events
to zero. Achieving that goal via the cycle of reporting, intervention, and measurement of subsequent outcomes must begin with a culture of openly reporting these events within the institution.
Many states have mandated reporting of these incidents whenever they occur, and an even more states mandate reporting of serious adverse events.
Health care facilities are accountable for correcting systematic problems that contributed to the event, with some states mandating performance of a root cause analysis and reporting its results.
Health Care Never Events
- Surgical Events
- Surgery performed on the wrong body part
- Surgery performed on the wrong patient
- Wrong surgical procedure performed on a patient
- Unintended retention of a foreign object in a patient after surgery or other procedure
- Intraoperative or immediately postoperative deatn in an ASA Class I patient
- Artificial insemination with the wrong sperm or donor egg
- Product or Device Events
- Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the health care facility
- Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used for functions orhter than as intended
- Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a health care facility
- Patient Protection Events
- Infant discharged to the wrong person
- Patient death or serious disability associated with patient elopement (disappearance)
- Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a health care facility
- Care Management Events
- Patient death or serious disability associated with a medication error (eg errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration
- Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products
- Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility
- Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility
- Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
- Stage 3 or 4 pressure ulcers acquired after admission to a health care facility
- Patient death or serious disability due to spinal manipulative therapy
- Environmental Events
- Patient death or serious disability associated with an electric shock or electrical cardioversion while being cared for in a health care facility
- Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
- Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility
- Patient death or serious disability associated with a fall while being cared for in a health care facility
- Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility
- Criminal Events
- Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider
- Abduction of a patient of any age
- Sexual assault on a patient within or on the grounds of the health care facility
- Death or significant injury of a patient or staff member resulting from a physical assault (ie, battery) that occurs within or on the grounds of the health care facility
Strategies to reduce risk
Strategies to improve the defensibility of care where appropriate, particularly those falling under the non-preventable adverse events list include:
- Pretreatment or pre-hospital documentation of underlying pre-existing conditions, particularly those involving infections, pressure sores, altered mental status, hyper-/hypoglycemia, and patients at high risk for venous thromboembolism.
- Hospital outcomes data with identification of care improvements directed at those complications - particularly hospital-acquired infections.
- Standardized and universally followed approaches to reduce wrong site/wrong patient surgery.
- Culture-changing training around communication, assertiveness, team training, and the use of briefings and debriefings, particularly in high-acuity patient care areas.
- The use of surgical checklists.
- Understanding and using clear language in policies and publications of the difference between the NQF
never events
and the CMSnon-reimbursable serious hospital-acquired conditions
to avoid claims of negligence.
Confusion persists about the definition of never events
as they relate to either (1) conditions listed as serious reportable events
by NQF, or (2) conditions defined by CMS as non-reimbursable serious hospital-acquired conditions
. While most on the list of serious reportable events
include obvious unacceptable errors, such as wrong site surgery or discharge of an infant to the wrong person, not all such events are preventable at all times or indicative of obvious negligence (for example, patient falls, postoperative infections and thromboembolic events). A goal of quality improvement measures should be to institute a reduction of never events
to zero. Achieving that goal via the cycle of reporting, intervention, and measurement of subsequent outcomes must necessarily begin with a culture of openly reporting these defined events within an institution.
Introducing a positive approach towards patient safety: Always Events
Never Events
and non-reimbursable adverse events are framed in the negative and likely carry some extra psychological charge
, as mentioned above. Our concept of the always events
represents a positive affirming behavior that can motivate us to improve patient safety and promote better outcomes. Some basic examples of always events
include:
- Including patient identification by more than one source.
- Mandatory
readbacks
of verbal orders for high-alert medications. - Disclosure of adverse outcomes and transparency with patients and families.
- Medication error reduction strategies.
- Surgical time-out.
- Anesthesia monitoring that is appropriate for the level of sedation.
- Tracking of critical imaging, lab and pathology results.
- Making critical information available at handoffs or transitions in care.
Standardization and validation of always events
may represent the basis for a positive long-term culture of patient safety.
References
- Agency for Healthcare Research and Quality (AHRQ) Never Events www.psnet.ahrq.gov
- Lembitz A, Clarke TJ. Clarifying "never events" and introducing "always events" www.ncbi.nlm.nih.gov