Never Events

From SmartMedicalConsumer Wiki

Never events are serious and costly errors in the provision of health care services that should never happen. Never events, like surgery on the wrong body part or mismatched blood transfusion, cause serious injury or death to beneficiaries, and result in increased costs to the Medicare program and private insurers to treat the consequences of the error.

National Quality Forum (NQF), a voluntary consensus standard-setting organization, developed this list with support from CMS.

The Centers for Medicare & Medicaid Services issued a rule in August 2007 and set to take effect in October 2008, that denies payment for eight hospital-acquired conditions. Five of the eight -- pressure ulcers, air embolism, blood incompatibility, object left in patient after surgery, and patient falls -- also are NQF-endorsed never events. In April 2008, CMS is proposing to add an additional nine categories of conditions that when acquired in the hospital will no longer lead to higher Medicare payment, including one from the NQF Never Event list associated with hypoglycemia.

It is widely expected that even more private payers will follow Medicare's lead in this area once the rule has been successfully implemented.

The BlueCross BlueShield announced in November 2007 that its plans will work toward ending payment for never events. The change will be phased in over several years. (See Wall Street Journal).

Many hospitals also have pledged to waive all costs directly associated with never events. In September 2007, Minnesota hospitals and insurers agreed that patients and health plans should not be billed for care associated with a list of 28 never events endorsed by the NQF. In December 2007, 61 Massachusetts hospitals announced they will stop charging for nine NQF-defined never events, such as sending a baby home with the wrong family or performing a procedure on the wrong patient.

According to the National Quality Forum (NQF), never events are 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. NQF

Current List of Never Events

Surgical Events

• Surgery performed on the wrong body part
• Surgery performed on the wrong patient
• Wrong surgical procedure on a patient
• Retention of a foreign object in a patient after surgery or other procedure
• Intraoperative or immediately post-operative death in a normal health patient (defined as a *Class 1 patient for purposes of the American Society of Anesthesiologists patient safety initiative

Product or Device Events

• Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
• Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
• Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility

Patient Protection Events

• Infant discharged to the wrong person
• Patient death or serious disability associated with patient elopement (disappearance) for more than four hours
• Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility

Care Management Events

• Patient death or serious disability associated with a medication error (e.g., error involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)
• Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products
• Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy while being cared for in a healthcare facility
• Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
• Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
• Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
• Patient death or serious disability due to spinal manipulative therapy

Environmental Events

• Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
• Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
• Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
• Patient death associated with a fall while being cared for in a healthcare facility
• Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

Criminal Events

• Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
• Abduction of a patient of any age
• Sexual assault on a patient within or on the grounds of a healthcare facility
• Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility