never event pp
TRANSCRIPT
By-‐ Gisse)e Rios
• In 2007, 3 different Rhode Island Hospital surgeons performed 3 wrong-sided brain surgeries.
• Surgeon 1 ignored the nurse and stated he knew which
side of the brain he had to work on… he was wrong. • Surgeon 2 decided to skip the pre-operative check-list
and cut into the wrong side of the patient’s brain.
• Surgeon 3 just simply began surgery on the wrong side of the brain.
• 3 enormous medical errors performed during brain surgery all within one year!
In 2001, 99 Fremont, Nebraska cancer patients were infected with Hepatitis C, the worst outbreak of it’s kind in America. Hepatitis C virus (HCV) causes liver inflammation. The virus is commonly transmitted when a person comes in close contact with infected blood, usually by being stuck with a needle, as in injection drug use, body piercing, or tattooing. Nurses under orders from the oncologist Dr. Tahir Javed, had continuously failed to change the syringes used on patients. This story, along with the previous brain surgery errors, are perfect examples of “Never Events”.
• Never events are the "kind of mistake that should “never happen" in the field of medical treatment.
• According to the Leapfrog Group never events are defined as adverse events that are serious, largely preventable, and of concern to both the public and healthcare providers for the purpose of public accountability.
• The Ins0tute of Medicine’s (IOM’s) publica0on in 1999, To Err Is Human, called for a na0onwide public mandatory repor0ng system to iden0fy and learn from medical errors.
• The term "Never Event" was first
introduced in 2001 by Ken Kizer, MD, former CEO of the Na0onal Quality Forum (NQF), in reference to par0cularly shocking medical errors.
• Before the IOM reports, medical errors were generally considered acceptable consequences of care and remained deeply hidden.
• The National Quality Forum (NQF) was created in 1999 by a coalition of public-and private-sector leaders in response to the recommendation of the Advisory Commission on Consumer Protection and Quality in the Health Care Industry.
• The NQF is a nonprofit organization that aims to improve the quality of healthcare in the United States.
• The primary aim of the NQF is to improve healthcare by developing and implementing a national quality measurement and reporting system.
• In 2002, the NQF created a list of 27 “Serious Reportable Events” (SRE’s) which is the term the NQF uses for “Never Events”. Today the list contains 29 SRE’s.
Surgical Product or Device Pa0ent Protec0on -‐Wrong Body Part -‐Wrong Pa0ent -‐Wrong Procedure -‐Retained Foreign Object -‐Post-‐op death of an ASA Class I pa0ent
-‐Contaminated drugs/devices/biologics* -‐Device misuse/malfunc0on* -‐Air embolism*
-‐Infant discharged to wrong person -‐Pa0ent elopement* -‐Pa0ent suicide/a)empted suicide*
Care Management Environmental Poten0al Criminal
-‐Medica0on Errors* -‐Blood Products* -‐Maternal death/disability in a low-‐risk pregnancy* -‐Hypoglycemia* -‐Hyperbilirubinemia* -‐Stage 3 or 4 Pressure Ulcer -‐Spinal manipula0on* -‐Ar0ficial insemina0on error -‐Pa0ent fall*
-‐Electric Shock* -‐Oxygen/gas lines* -‐Burn* -‐Fall* -‐Physical Restraints* (*) Denotes pa0ent death or serious disability required
-‐Impersona0on of a healthcare worker -‐Abduc0on of a pa0ent -‐Sexual assault on a pa0ent -‐Physical assault of a pa0ent or staff member*
Clearly identifiable and measurable, and therefore likely to include in a reporting system.
Of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the health care facility.
Of concern to both health care providers and the public.
According to the NQF, in order for a “Never Event” to be reported, it must be:
NQF is doing this by focusing on three main goals:
1. Reducing preventable hospital admissions and readmissions.
2. Reducing the incidence of adverse healthcare-associated conditions. 3. Reducing harm from inappropriate or unnecessary care.
The Leapfrog Group is a a nonprofit quality-improvement organization whose members work to improve regulations surrounding the quality of healthcare. According to the Leapfrog Group, in case of a never event, hospitals commit to follow these 4 steps:
1) Apologize to the patient 2) Report the event 3) Perform a root cause analysis 4) Waive costs directly related to the event.
• According to the IOM report “To Err is Human”, between 44,000-98,000 people die each year due to medical errors. • Little progress to date - measures of patient safety showed an
average annual improvement of just 1 percent.
• Approximately two million healthcare-associated infections occur annually in the United States, totaling an estimated $4.5 billion in hospital healthcare costs.
• According to patient safety researchers at Johns Hopkins University who conducted a very careful analyses of patient malpractice claims, estimate surgeons in the U.S:
-Leave a foreign object such as a sponge or a towel inside a patient’s body after an operation 39 times a week.
-Perform the wrong procedure on a patient 20 times a week -Operate on the wrong body site 20 times a week.
Steps Towards Minimizing Never Events
• Health IT • State repor0ng systems • “No Pay” for never events
Health IT
State Repor/ng Systems
“No-‐Pay’” Events
Health IT • The NQF is focused on making
healthcare beFer through the use of health informa/on technology.
• Electronic Medical Records
(EMR’s) make healthcare safer, coordinated, and allow data and informa/on to be shared between IT systems.
• Clinical decision support • Computerized disease registries • Computerized provider order entry • Electronic medical record systems (EMRs, EHRs, and PHRs) • Electronic prescribing
• 26 states and the District of Columbia have state repor0ng systems for never events.
• These reports help healthcare workers iden0fy and learn from the
SRE’s.
• Although most states follow the list of NQF’s never events, the differences in the state’s approach to repor0ng events hinder the NQF’s efforts in finding out a precise number of how many never events actually occur.
• Minnesota, Connec0cut and New Jersey applied mandatory
legisla0on to report SREs within their own state-‐based repor0ng system.
• In 2008, the Centers for Medicare & Medicaid Services (CMS) announced they will no longer pay hospitals for a list of 8 Hospital-‐Acquired Condi0ons (HACs).
• Many private insurance companies also began to cease payment for a list of never events.
• This was done in efforts to minimize the amount of preventable errors that occur and mo0vate healthcare workers to avoid making these preventable mistakes.
1. Pressure ulcer stages III and IV 2. Falls and trauma 3. Surgical site infec0on ajer bariatric surgery for obesity 4. Vascular-‐catheter associated infec0on 5. Catheter-‐associated urinary tract infec0on 6. Administra0on of incompa0ble blood 7. Air embolism 8. Foreign object uninten0onally retained ajer surgery
Category 1 – Health Care-‐Acquired Condi/ons (For Any Inpa0ent Hospitals Semngs in Medicaid) • Foreign Object Retained ATer Surgery • Air Embolism • Blood Incompa/bility • Stage III and IV Pressure Ulcers • Falls and Trauma; including Fractures, Disloca/ons,
Intracranial Injuries , Crushing Injuries, Burns, Electric Shock
• Catheter-‐Associated Urinary Tract Infec/on (UTI) • Vascular Catheter-‐Associated Infec/on • Manifesta/ons of Poor Glycemic Control • Surgical Site Infec/on Following:
– Coronary Artery Bypass GraT – Bariatric Surgery – Orthopedic Procedures; including Spine, Neck,
Shoulder, Elbow • Deep Vein Thrombosis (DVT)/Pulmonary Embolism
(PE) Following Total Knee Replacement or Hip Replacement
• Iatrogenic Pneumothorax with Venous Catheteriza/on
Category 2 – Other Provider Preventable Condi/ons (For Any Health Care Semng) • Wrong Surgical or other
invasive procedure performed on a pa0ent
• Surgical or other invasive procedure performed on the wrong body part
• Employee Engagement -‐ Emo0onal a)achment employees feel towards workplace.
-‐ Connec0on between employee engagement and healthcare outcomes. -‐ Studies have shown that hospitals with higher nurse engagement levels have sta0s0cally lower mortality and complica0on issues.
• Root Cause Analysis -‐ A method of problem solving used for iden0fying the “root causes” of faults or problems. -‐Very important for management to perform a root cause analysis ajer a never event in order to inves0gate the issue and begin the process of solving the problem.
References AHRQ Pa0ent Safety Network -‐ Never Events. (n.d.). Retrieved April 2, 2015, from h)p://psnet.ahrq.gov/primer.aspx?primerID=3 Health IT . (n.d.). Retrieved March 30, 2015, from h)p://www.qualityforum.org/HealthIT Hospitals: Never Have a Never Event. (n.d.). Retrieved April 2, 2015, from h)p://www.gallup.com/businessjournal/118255/hospitals-‐ event.aspx Johns Hopkins Malprac0ce Study: Surgical 'Never Events' Occur At Least 4,000 Times per Year -‐ 12/19/2012. (n.d.). Retrieved April 1, 2015, from h)p://www.hopkinsmedicine.org/news/media/releases/ johns_hopkins_malprac0ce_study_surgical_never_events_occur_at_least_4000_0mes_per_year Lembitz, A., & Clarke, T. (n.d.). Clarifying "never events and introducing "always events" Retrieved April 1, 2015, from h)p:// www.ncbi.nlm.nih.gov/pmc/ar0cles/PMC2814808/ (n.d.). Retrieved April 3, 2015, from h)p://www.ahrq.gov/professionals/quality-‐pa0ent-‐safety/pa0ent-‐safety-‐resources/resources/ advances-‐in-‐pa0ent-‐safety/vol4/Kizer2.pdf (n.d.). Retrieved April 1, 2015, from h)ps://www.iom.edu/~/media/Files/Report Files/1999/To-‐Err-‐is-‐Human/To Err is Human 1999 report brief.pd (n.d.). Retrieved April 1, 2015, from h)p://www.leapfroggroup.org/media/file/Leapfrog-‐Never_Events_Fact_Sheet.pdf When Surgeons Cut the Wrong Body Part. (2007, November 28). Retrieved April 1, 2015, from h)p://well.blogs.ny0mes.com