Never Event Paper
Never Events and Hospital Acquired Infections
Hospital is the place to go when someone is sick and requires medical attention. It is shocking to know that one can contract diseases while in the hospital facility which were not present during admission. And that ‘Never Events’ which are preventable incidents such as wrong site surgery do occur in the hospital setting. How do we prevent hospital acquired conditions and never events from occurring in the hospital? It will be interesting to figure out the answers to these questions as hospital acquired conditions and Never Events are the major concerns of the health care system.
Never-Events and Hospital Acquired Conditions A Never Event has been defined by the National Quality Forum (NQF) as, “errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility” (Dalcon, 2010). On the other hand, Hospital Acquired Conditions (HAC) are defined as preventable conditions that the patient did not have upon entering the hospital, but gained while in custody of the hospital (Dalcon, 2010).
The Centers for Medicare & Medicaid Services (CMS) requires all their participating hospitals to disclose all hospital acquired conditions and would deny reimbursement for cost acquired from such events. The HACs identified by the Center for Medicare & Medicaid Services include the following: objects left in patients after surgery, air embolism, blood incompatibility, catheter-associated urinary tract infection, pressure ulcers, surgical site infections, hospital acquired injury due to external causes such as fractures, dislocations, intracranial injury, crushing injury, burns etc (Dalcon, 2010). In an effort to provide and pay for better quality care, CMS is investigating ways to prevent and eliminate the occurrence of never events that contribute to serious and costly errors that happens in the
Hospital is the place to go when someone is sick and requires medical attention. It is shocking to know that one can contract diseases while in the hospital facility which were not present during admission. And that ‘Never Events’ which are preventable incidents such as wrong site surgery do occur in the hospital setting. How do we prevent hospital acquired conditions and never events from occurring in the hospital? It will be interesting to figure out the answers to these questions as hospital acquired conditions and Never Events are the major concerns of the health care system.
Never-Events and Hospital Acquired Conditions A Never Event has been defined by the National Quality Forum (NQF) as, “errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility” (Dalcon, 2010). On the other hand, Hospital Acquired Conditions (HAC) are defined as preventable conditions that the patient did not have upon entering the hospital, but gained while in custody of the hospital (Dalcon, 2010).
The Centers for Medicare & Medicaid Services (CMS) requires all their participating hospitals to disclose all hospital acquired conditions and would deny reimbursement for cost acquired from such events. The HACs identified by the Center for Medicare & Medicaid Services include the following: objects left in patients after surgery, air embolism, blood incompatibility, catheter-associated urinary tract infection, pressure ulcers, surgical site infections, hospital acquired injury due to external causes such as fractures, dislocations, intracranial injury, crushing injury, burns etc (Dalcon, 2010). In an effort to provide and pay for better quality care, CMS is investigating ways to prevent and eliminate the occurrence of never events that contribute to serious and costly errors that happens in the
References: AHRQ Patient Safety Network (2009). “Never Events.” Retrieved from http://www.psnet.ahrq.gov/primer.aspx?primerID=3 Centers for Medicare and Medicaid Services. (2006). “Press release: Eliminating Serious, Preventable and Costly Medical Errors – Never Events.” Retrieved from www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863 Dalcon. (2010). “Never Events and HACs” Dalcon Communications. Retrieved from http://www.dalcon.com/healthcare/dalcon-alert/never-events-and-hacs/ Lembitz, A., & Clarke, T. (2009). “Clarifying 'Never ‘Events ' and Introducing 'Always Events '.” Patient Safety in Surgery. 3(26).