Never Events vs Always Events Eli Grambling Andre

Never Events vs. Always Events Eli Grambling Andre Hiroaki Nakamura Julia Caetano Barbosa Lembitz, Alan, and Ted Clarke. "Clarifying "never Events" and Introducing "always Events"" Patient Safety in Surgery. 31 Dec. 2009. Web. 11 Feb. 2015. <http: //www. pssjournal. com/content/3/1/26>. 1

“Never Events” Defined by National Quality Forum (NQF) as “serious reportable events” Centers for Medicaid and Medicare Services (CMS) define never events as “non-reimbursable serious hospital-acquired conditions” Confusion continues as to true definition of “Never Events” Eli Grambling, Andre Nakamura, Julia Barbosa 2

“Never Events” - NQF – nonprofit company that aims to improve healthcare in U. S. Reported in 2006, 28 known “serious reportable events” Incidents largely preventable Goal of Quality Improvement is to reduce “Never Events” to 0 Table 1. Gives a list of the 28 events http: //www. pssjournal. com/content/3/1/26/table/T 1 Eli Grambling, Andre Nakamura, Julia Barbosa 3

“Never Events” - CMS Provided definition in order to motivate hospitals to improve patient safety Goal – to implement standard protocols to follow Non-reimbursable conditions apply only to scenarios listed as “reasonably preventable” Figure 1. Gives comparison of CMS to NQF “Never Events” http: //www. pssjournal. com/content/3/1/26/figure/F 1 Eli Grambling, Andre Nakamura, Julia Barbosa 4

“Never Events” - CMS Examples of Liability Concerns and Negligence Claims 1) Prevention of Falls 2) Postoperative infections and thromboembolic events Eli Grambling, Andre Nakamura, Julia Barbosa 5

Strategies To Reduce Risk Hospital documentation of pre-existing injuries/conditions Hospital data that dealt with pre-existing injuring/conditions Implementation of Standard Protocols Further Training Surgical Checklists Clear use of common language Eli Grambling, Andre Nakamura, Julia Barbosa 6

“Always Events” Always events as opposed to never events bring a positive connotation rather than the negative connotation associated with never events Eli Grambling, Andre Nakamura, Julia Barbosa 7

“Always Events” Examples: 1) Multiple Source Patient Identification 2) Verbal order feedback 3) Documentation of patient outcomes and response to family 4) Medical error reduction strategies 5) “Surgical time-out” 6) Monitoring of proper Anesthesia dose 7) Critical Imaging records tracking 8) Critical Information availability Eli Grambling, Andre Nakamura, Julia Barbosa 8

Source Lembitz, Alan, and Ted Clarke. "Clarifying "never Events" and Introducing "always Events"" Patient Safety in Surgery. 31 Dec. 2009. Web. 11 Feb. 2015. <http: //www. pssjournal. com/content/3/1/26>. Eli Grambling, Andre Nakamura, Julia Barbosa 9

Questions? Eli Grambling, Andre Nakamura, Julia Barbosa 10