Never Events
Dr. Ken Keizer, the former CEO of the National Quality Forum (NQF), initially used the term “never events” in 2001 to describe medical occurrences that ought never to take place, such as incorrect site procedures, etc. The number of events connected to this term has increased since then and presently stands at 29. Many state and commercial insurers followed the Centers for Medicare and Medicaid Services (CMS) decision to refuse reimbursement for any expenditures of care related to these “never occurrences” in 2007. However, many states have enacted reporting laws forcing facilities to disclose “never events” and, in some situations, negative incidents as well. This helps to prevent such occurrences, raise awareness, and hold facilities accountable (Patient Safety Network (PS Net), 2019).
When “never occurrences” happen, facilities must deal with several detrimental effects. They must first cover the expense of any care and treatment related to the incident. These fees may be substantial. In addition to the immediate expenditures incurred, the publicity surrounding such an incident may result in a reduction in services as a result of public concern for their own safety in a facility after such tragic incidents. Together, these two elements have the potential to bankrupt any facility.
Facilities, therefore, work to avoid these occurrences. Facilities educate staff members on the rules, procedures, and protocols that have been developed to prevent such situations and raise employee understanding of what circumstances are never considered events. Also, routine training sessions that differ depending on the various units are held to help maintain a safe current. The quality and safety of patient care improve with a more knowledgeable and informed workforce.
In one study, the rates of central line-associated bloodstream infections (CLABSIs) and catheter-acquired urinary tract infections (CAUTIs) both significantly decreased by 10% and 11%, respectively. Hospitals “still struggle to discover evidence-based practices that significantly improve HAPUs and injurious falls,” according to the study’s analysis of hospital-acquired pressure ulcers (HAPUs) and injurious inpatient falls (Waters et al., 2015). This shows that there was space for development inside the facilities, and thanks to the demands of the governing and enforcement bodies, patients today receive care that is of a higher caliber in many areas.
Rep. Lois Capps has undoubtedly been a very powerful figure in the nursing community. She was given the 2013 Congressional Nurse Advocacy Award by the American Nurses Association (ANA), which recognized her accomplishments and excellence in service. Although she made numerous contributions, the Registered Nurse Safe Staffing Act was significant. According to the law, hospitals were required to create flexible staffing plans depending on a variety of variables with a panel made up of RNs. By proxy, this action benefits not just the nursing profession but also patient safety and care quality (McCutcheon, 2015). For this measure, Capps gained backing from the ANA. Due to the organization’s immense size and power, such assistance might be crucial in bringing about change. If we want to affect change, we must work together as a team.
In an effort to “motivate hospitals to accelerate the improvement of patient safety by the implementation of established standards,” the Center for Medicare and Medicaid Services (CMS) developed the policy denying reimbursement for “never events” (Lembitz & Clarke, 2009). According to the Medicare Advisory Committee, this represents a modest step toward raising quality and cutting wasteful spending. In fact, Kenneth Kizer, the physician who first used the term “never events,” explains how this phrase has a negative psychological connotation known as “negative framing,” as “humans are more strongly inclined to take action when the consequences of failing to act are mentally vivid and when the actions in question are labeled so as to convey the loss avoided (rather than the benefit gained)” (Lembitz & Clarke, 2009).
Derese, The statement that “more resources should be devoted toward preventing catastrophic disasters rather than paying more when they occur” strikes me as being very true. The key is to prevent. They increase quality and safety while lowering expenses. As nurses, we are aware of what goes on during the caregiving process and have firsthand experience with what happens when the right stages are skipped, and corners are cut. As a nurse, I appreciate the improved awareness, training, and upgrading of the procedures, rules, and protocols utilized to stop them from happening. Both as a nurse and a temporary patient, I feel safer.
This is not easy. With their position of authority, doctors may find it difficult to speak up. They can be very intimidating and occasionally lash out and be disrespectful, despite the fact that they are not our bosses and we are supposed to work together as a creative team.
As nurses, it is our duty to speak out and act as champions for the health of our patients. Gelling in and out is a technique to protect the safety of our patients. Institutions have even gone so far as to encourage patients to hold their caregivers accountable by noting whether they had washed their hands before caring for them and, if not, requesting that they do so. This promotes responsibility and wellness.
Bonnie,
I concur entirely. While many of these avoidable adverse outcomes, including hospital-acquired infections, might result from the system as a whole failing, not one specific individual, the blame should not be placed on a single nurse. Because of this, it is important for hospitals to stay up to date on the most recent evidence-based procedures and to seek to streamline the processes so that they become part of standard medical care. In order to deliver such safe and high-quality care, hospitals must provide the right environment, tools, and guidance for nurses, who have a variety of duties to do during a shift.
References:
Patient Safety Network. (2019). Never Events. Retrieved from https://psnet.ahrq.gov/primers/primer/3/never-events
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: https://dx.doi.org/10.1001%2Fjamainternmed.2014.5486
McCutcheon, S. (2015). ANA praises retiring U.S. Rep. Capps for advocacy for RNs, public health. Retrieved from http://www.theamericannurse.org/2015/04/17/ana-praises-retiring-u-s-rep- 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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Question 
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
- 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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