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Never Events

Never Events

Never Events

The term “never events” was first coined in 2001 by Dr. Ken Keizer, former CEO of the National Quality Forum (NQF), which represented medical events that should never occur like wrong site surgeries, etc. Since then, the events associated with this term have grown in number to now include 29 events. In 2007 the Centers for Medicare and Medicaid Services (CMS) decided to deny reimbursement for any costs of care associated with these “never events” and many state and private insurers followed suit. Furthermore, many states have enforced reporting mandates requiring facilities to publicly report such “never events” and in some cases adverse events as well. This aids in raising awareness, helping to keep facilities accountable, and help to prevent future instances (Patient Safety Network (PS Net), 2019).

Facilities face many negative consequences when “never events” occur. First, they must absorb the cost associated with all care and treatment associated with the event. These costs can be hefty. In addition to the direct costs lost, the publicity associated with such an event can lead to a decrease in services as the public becomes fearful for their own safety in a facility when these serious events have occurred. Both these factors together can be financially crippling to any facility.

Therefore, facilities aim to prevent these events. Facilities increase the awareness among the staff of what events are consisted never events, and educated them on what policies, procedures, and protocols have been created to prevent such occurrences. Routine training are also held and can vary based on individual units which aid in keeping the safe current. With a more educated and aware staff, the quality and safety of patient care rise.

One study found a significant reduction in catheter acquired urinalysis tract infects (CAUTIs) by 10% and central line–associated bloodstream infections (CLABSIs) by 11%. The study also researched hospital-acquired pressure ulcers (HAPUs) and injurious inpatient falls finding “hospitals still struggle to identify evidence-based practices that significantly improve HAPUs and injurious falls” (Waters et al., 2015). This indicates there was room for improvement within facilities, and by governing and enforcement agencies demanding a rise improvement of care, patients now receive a higher quality of care in many areas.

Rep. Lois Capps has truly been a highly influential member within the nursing profession. Recognizing her achievements and excellence is serving, she received the American Nurses Association’s (ANA) Congressional Nurse Advocate award in 2013. While her contributions were many, the Registered Nurse Safe Staffing Act was huge. The act called on hospitals to develop flexible staffing plans based on a number of factors with a panel comprised of RNs. This act not only aids the nursing profession, but the safety and quality of care by proxy (McCutcheon, 2015). Capps received support from the ANA with regards to this act. Such support can be monumental in achieving change due to the sheer size and influence such an organization possesses. We must unite as a team if we are to cause change.

The Center for Medicare and Medicaid Services (CMS) developed the policy to deny reimbursement for “never events” in the hopes “to motivate hospitals to accelerate improvement of patient safety by implementation of standardized protocols” (Lembitz & Clarke, 2009). The Medicare Advisory Commission considers this to be a small step in improving quality and reducing wasted spending. In fact, Kenneth Kizer, the MD responsible for coining the term “never events,” explains how this term creates a negative association at a psychological level, referred to as “negative framing” as “humans are more strongly inclined to take action when the actions in question are labeled so as to convey the loss avoided (rather than the benefit gained) and when the consequences of failing to act are mentally vivid” (Lembitz & Clarke, 2009).

Derese, I think that is an excellent point that “more resources to be directed toward preventing these events rather than paying more when they occur.” Prevention is key. They not only decrease costs but to improve quality and safety. As nurses we are privy to what happens in the steps to provide care and can see first-hand what occurs when proper steps are not taken, and corners are cut. As a nurse I am glad for the increased attention and training, and the updating of policies, procedures, and protocols used to prevent them from occurring. I feel safer as a nurse and a transient patient.

This is definitely a struggle. Speaking up can be challenging as doctors are in a position of authority. Even though they are not are bosses and we are to work together as a collaborative team, they can be very intimidating and sometimes lash out and be demeaning.

Gelling in and out is a practice to ensure the safety of our patients and as nurses it is our responsibility to speak up and be advocates for our patient’s health. Facilities have even gone so far as to encourage patents to hold their caregivers accountable by noting if they have performed hand hygiene prior to their care, and if not request that they do so. This helps to maintain accountability and health.


I completely agree. The fault should not lie with one individual nurse, as many of these preventable adverse events such as hospital acquired infections can occur from the system as a whole failing, not one specific individual. This is why is it critical for facilities to remain current with current evidence-based practices and work to streamline the protocols making them part of routine care. Nurses have many responsibilities within a shift, and therefore are reliant on facilities to provide the proper setting, resources, and direction to make such safe and quality care possible.


Patient Safety Network. (2019). Never Events. Retrieved from

Waters, T. M., Daniels, M. J., Bazzoli, G. J., Perencevich, E., Dunton, N., Staggs, V. S., Potter, C., Fareed, N., Lui, M., and Shorr, R. I.. (2015). Journal of the American Medical Association (JAMA) Internal Medicine, 175(3), 347-354.doi:

McCutcheon, S. (2015). ANA praises retiring U.S. Rep. Capps for advocacy for RNs, public health. Retrieved from capps-for-advocacy-for-rns-public-health/

Lembitz, A. & Clarke, T. J. (2009). Clarifying “never events and introducing “always events”. Patient Safety in Surgery, 3(26). doi: 10.1186/1754-9493-3-26


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The Centers for Medicare & Medicaid Services (CMS) formed its no-pay policy based on the growing work of National Quality Forum (NQF) of “never events.” Meaning, CMS will no longer pay for certain conditions that result from what might be termed poor practice or events that should never have occurred while a patient was under the care of a healthcare professional.

never events

never events

  • Discuss specific examples of “never events” and their impact in your workplace.
  • What issues are you considering for your clinical project and why?

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