Never Events
Instructions:-
What are ‘never events’?
What significance will they have on healthcare?
3 pages; 3 references required; name, date, page #, assignment name, and your name on each page in the header section.
Please describe what never events are and how they are classified so to speak
Please mention how reimbursements are affected by ‘never events’.
Please talk about :
patient falls also.
catheter associated Urinary tract infections CAUTIS
CLABSI’s or Central line infectionsSt. Dominic’s Hospital, who i am employed by is always chasing zero!
Solution
Never Events
Introduction
Nurses are tasked with some of the most difficult of duties, one of them is ensuring the safety of all the patients that visit a hospital. Their implementation of evidence-based standards in the delivery of their services is what helps them keep their patients from harm, but they can only use these methods effectively by having sound staffing plans that facilitate the delivery of their services (Keogh & Beasley, 2011). The plans also help nurses to be in adequate numbers so that the delivery of services to patients is efficient and timely. Amendments to different healthcare bills have however affected the ability of nurses to protect patients thus putting them at a disadvantage within the public eye. Events brought by such factors are known as never events (Gitlow et al., 2013).
“Never Events” Description
Also referred to as Serious Reportable Events (SRE), never events are medical errors that occur as a result of misguided procedures applied when taking care of patients Gitlow et al., 2013; Hrehocik, 2010; Keogh & Beasley, 2011; Lucero, Lake, & Aiken, 2010; Mehtsun, Ibrahim, Diener-West, Pronovost, & Makary, 2013 . Such errors have led to the death of about 44,000-98,000 Americans every year. The main basis for the explanation of the never events is that “To err is human” in that no human being is perfect thus it is allowable for one to make errors in his/her line of work. Even though humans are susceptible to making errors, some of them are preventable, and that is the case in the SREs. A study by the National Quality Forum (NQF) found out that most of these events were avoidable in the circumstances that they took place. Concern by both the public and healthcare providers led to the development of a medical errors reporting system to help identify where the problems were (Barach, 2000; Poorolajal, Rezaie, & Aghighi, 2015).
Categories of Never Events
Care Management Events
These are never events which are mainly affected by poor administration by the health care facility. The poor administration services may range from the supply and delivery of drugs to the procurement of medical equipment which may cause harm or death to the patients in the health care facility (Mehtsun et al., 2013; Thiels et al., 2015).
Environmental Events
These never events are mainly influenced by the environmental factors in a healthcare facility. Such environmental factors include gas systems, electricity, sources of heat that may cause burns and exposure to toxic substances. Should the influence of any of these factors result in the serious injury or death of a patient, it constitutes an environmental event (Reid, 2011).
Patient Protection Events
Three circumstances qualify to constitute a patient protection event. The first circumstance entails an event where a patient dies or gets injured. Second, the release of a patient of any age who is unable to make decisions to anyone other than an authorized person. Third, patient suicide or any suicide-related activity that results in serious injury while being cared for in the healthcare setting (Fry, 2010).
Surgical Events
These events are determined by the occurrence of one of five instances. One case includes the performance of a surgical procedure on a wrong patient. Another case involves the performance of a surgical procedure on the correct patient but the wrong body part. A wrong surgical procedure performed on a patient also amounts to a surgical event. The unintended retention of a foreign object in a patient’s body after surgery also constitutes a surgical event. An intraoperative death in an ASA Class I patient (Thiels et al., 2015).
Device Events
These are also known as product events. They are characterized by the occurrence of one of three instances. The first instance includes when a patient dies or becomes disabled due to the use of contaminated drugs, biologics or devices provided by the hospital. Second, an event where a patient dies or becomes disabled due to the misuse of a device from its original intention. The third event entails a situation where a patient dies or becomes disabled when an intravascular air embolism occurs while the patient is cared for in the healthcare setting (Makar, Kodera, & Bhayani, 2015).
Radiologic Events
These never events occur as a result of the serious injury or death of a patient after the introduction of a metallic object into the MRI area (Makar et al., 2015).
Potential Criminal Events
These never events are influenced by the impersonation of any healthcare provider, abduction of a patient and sexual assault of a patient or staff member within the healthcare facility (MacLeod, 2010).
Reimbursement Policy
The reimbursement policy for healthcare facilities hinges on the ability of a hospital to reduce the occurrence of never events in their premises. By avoiding the never events, the funds that would have been lost during the occurrence of the events are pumped back into the hospital’s account to help it research on ways to reduce such events. For example, by preventing four events, a hospital could save $500,000 to $5 million depending on the size and type of never event that occurred. The hospital receives the funds indirectly and uses the funds to treat never events without billing the affected patients or the insurers (Keogh & Beasley, 2011).
CAUTIS Events
Those affected by catheter-associated urinary tract infections (CAUTIS) are classified under device events. Their infections are mainly affected by the interaction of a patient with a catheter. Patients get easily infected when the catheters are used for different purposes apart from those that they are intended for, and as such, these infections cost hospitals about $83,365 per infected patient. The instances of CAUTIS infections are however lower than other never events, and major hospitals have dealt with them accordingly (Di Leonardo, Marcia, & Karen, 2012).
Conclusion
Never events are manageable within this day and age
due to the development of research and allowance for minor errors. Nurses and
other healthcare professionals should take care of their patients with utmost
precision and dignified healthcare procedure.
References
Barach, P. (2000). Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ, 320(7237), 759–763. https://doi.org/10.1136/bmj.320.7237.759
Di Leonardo, B. C., Marcia, F., & Karen, S. (2012). Preventing Never Events: Evidence Based Nurse Staffing (Vol. 92130). San Diego, California,US.
Fry, D. E. (2010). Patient Characteristics and the Occurrence of Never Events. Archives of Surgery, 145(2), 148. https://doi.org/10.1001/archsurg.2009.277
Gitlow, H., “Amy” Zuo, Q., Ullmann, S. G., Zambrana, D., Campo, R. E., Lubarsky, D., & Birnbach, D. J. (2013). The causes of never events in hospitals. International Journal of Lean Six Sigma, 4(3), 338–344. https://doi.org/10.1108/IJLSS-03-2013-0016
Hrehocik, M. (2010). Put an end to “never events”. In Long-Term Living: For the Continuing Care Professional (Vol. 59, p. 8).
Keogh, S. B., & Beasley, D. C. (2011). Policy update: never events. Nursing Times, 107(23), 12–13.
Lucero, R. J., Lake, E. T., & Aiken, L. H. (2010). Nursing care quality and adverse events in US hospitals. Journal of Clinical Nursing, 19(15–16), 2185–2195. https://doi.org/10.1111/j.1365-2702.2010.03250.x
MacLeod, J. B. A. (2010). Broadening Never Events: Is It a Plausible Road to Improved Patient Safety? Archives of Surgery, 145(2), 151. https://doi.org/10.1001/archsurg.2009.278
Makar, A., Kodera, A., & Bhayani, S. B. (2015). Never Events in Surgery. European Urology. https://doi.org/10.1016/j.eururo.2015.06.038
Mehtsun, W. T., Ibrahim, A. M., Diener-West, M., Pronovost, P. J., & Makary, M. A. (2013). Surgical never events in the United States. Surgery (United States), 153(4), 465–472. https://doi.org/10.1016/j.surg.2012.10.005
Poorolajal, J., Rezaie, S., & Aghighi, N. (2015). Barriers to medical error reporting. International Journal of Preventive Medicine, 2015–October. https://doi.org/10.4103/2008-7802.166680
Reid, J. H. (2011). Surgical Never Events should never happen… Journal of Perioperative Practice, 21(11), 373–378.
Thiels, C. A., Lal, T. M., Nienow, J. M., Pasupathy, K. S., Blocker, R. C., Aho, J. M., … Bingener, J. (2015). Surgical never events and contributing human factors. Surgery (United States), 158(2), 515–521. https://doi.org/10.1016/j.surg.2015.03.053