Never Events vs. Always Events

Eli Grambling

“Never Events” Defined by National Quality Forum (NQF) as

“serious reportable events” Centers for Medicaid and Medicare Services

(CMS) define never events as “non-reimbursable serious hospital-acquired conditions”

Confusion continues as to true definition of “Never Events”

“Never Events” - NQF NQF – nonprofit company that aims to improve

healthcare in U.S. Reported in 2006, 28 known “serious

reportable events” Incidents largely preventable Goal of Quality Improvement is to reduce

“Never Events” to 0 Table 1. Gives a list of the 28 events

“Never Events” - CMS Provided definition in order to motivate

hospitals to improve patient safety Goal – to implement standard protocols to

follow Non-reimbursable conditions apply only to

scenarios listed as “reasonably preventable” Figure 1. Gives comparison of CMS to NQF

“Never Events”

“Never Events” - CMS Examples of Liability Concerns and Negligence

Claims1) Prevention of Falls2) Postoperative infections and thromboembolic

events

Strategies To Reduce Risk Hospital documentation of pre-existing

injuries/conditions Hospital data that dealt with pre-existing

injuring/conditions Implementation of Standard Protocols Further Training Surgical Checklists Clear use of common language

“Always Events” Always events as opposed to never events

bring a positive connotation rather than the negative connotation associated with never events

“Always Events” Examples:1) Multiple Source Patient Identification2) Verbal order feedback 3) Documentation of patient outcomes and

response to family4) Medical error reduction strategies5) “Surgical time-out”6) Monitoring of proper Anesthesia dose7) Critical Imaging records tracking8) Critical Information availability

Source http://www.pssjournal.com/content/3/1/26