Clarifying "never events" and introducing "always events"

  • PDF / 180,742 Bytes
  • 5 Pages / 610 x 792 pts Page_size
  • 44 Downloads / 199 Views

DOWNLOAD

REPORT


BioMed Central

Open Access

Editorial

Clarifying "never events" and introducing "always events" Alan Lembitz* and Ted J Clarke Address: Colorado Physician Insurance Company (COPIC), Headquarters, Denver, CO 80230, USA Email: Alan Lembitz* - [email protected]; Ted J Clarke - [email protected] * Corresponding author

Published: 31 December 2009 Patient Safety in Surgery 2009, 3:26

doi:10.1186/1754-9493-3-26

Received: 17 December 2009 Accepted: 31 December 2009

This article is available from: http://www.pssjournal.com/content/3/1/26 © 2009 Lembitz and Clarke; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Despite the widespread usage of the term "never events," the National Quality Forum (NQF) refers to these events as "serious reportable events" in all of their definitions and references. In this editorial, we use the popular - but likely improper - term "never events" as it further illustrates the public's perception of adverse occurrences. Although the preferred terminology reverts to "serious reportable events", this definition may be unlikely be given the prevalence of the viscerally moving term "never event." Further confusion persists about the definition of "never events" as they relate to either (1) conditions listed as "serious reportable events" by the NQF, in contrast to (2) conditions defined by the Centers for Medicare and Medicaid Services (CMS) have deemed as "non-reimbursable serious hospital-acquired conditions".

National Quality Forum (NQF) - definition of "never events" The NQF is a nonprofit organization that aims to improve the quality of healthcare in the United States http:// www.qualityforum.org. In 2002, the NQF published a first report which defined 27 so-called "serious reportable events" in healthcare. These encompass serious adverse events occurring in hospitals that are largely preventable and of concern to both the public and to healthcare providers. One additional event was added to the updated report in 2006, leading to a total 28 "never events" defined by the NQF (table 1) [1,2]. 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 NQF events are preventable at all times or indicative of obvious negligence [3]. 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 [4-6].

Centers for Medicare and Medicaid Services (CMS) - definition of "never events" CMS adopted the non-reimbursement policy for certain "never events" - defined as "non-reimbursable serious hospita