Never Events, Non-reimbursable Events, and Always Events

Never events are the "kind of mistake that should never happen" in the field of medical treatment.

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).

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

Strategies to reduce risk

Strategies to improve the defensibility of care where appropriate, particularly those falling under the non-preventable adverse events list include:

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:

Standardization and validation of always events may represent the basis for a positive long-term culture of patient safety.

References