Centers for Medicare and Medicaid Services

Hospital is the place to go when someone is sick and requires medical attention. It is shocking to know that one can contract diseases while in the hospital facility which were not present during admission. And that ‘Never Events’ which are preventable incidents such as wrong site surgery do occur in the hospital setting. How do we prevent hospital acquired conditions and never events from occurring in the hospital? It will be interesting to figure out the answers to these questions as hospital acquired conditions and Never Events are the major concerns of the health care system.

Never-Events and Hospital Acquired Conditions A Never Event has been defined by the National Quality Forum (NQF) as, “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” (Dalcon, 2010). On the other hand, Hospital Acquired Conditions (HAC) are defined as preventable conditions that the patient did not have upon entering the hospital, but gained while in custody of the hospital (Dalcon, 2010).

The Centers for Medicare & Medicaid Services (CMS) requires all their participating hospitals to disclose all hospital acquired conditions and would deny reimbursement for cost acquired from such events. The HACs identified by the Center for Medicare & Medicaid Services include the following: objects left in patients after surgery, air embolism, blood incompatibility, catheter-associated urinary tract infection, pressure ulcers, surgical site infections, hospital acquired injury due to external causes such as fractures, dislocations, intracranial injury, crushing injury, burns etc (Dalcon, 2010).

In an effort to provide and pay for better quality care, CMS is investigating ways to prevent and eliminate the occurrence of never events that contribute to serious and costly errors that happens in the provision of health care that should have been prevented (CMS, 2006). The NQF has listed a series of never events which jeopardize the quality of care given to patients. The examples include the following:

1. Surgery performed on wrong body part; wrong patient, wrong surgical procedure on patient, 2. Unintended retention of a foreign object in a patient after surgery or other procedures 3. Immediate postoperative death in an American Society of Anesthesiologist Class I patient 4. Artificial insemination with the wrong sperm or donor egg.

5. 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 6. 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 with toxic substances. 7. Infant discharged to the wrong person, Patient death or serious disability associated with patient elopement 8. Patient death or serious disability due to spinal manipulative therapy, 9.

Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility 10. Patient death or serious disability associated with a medication error, and the use or function of a device in patient care in which the device is used or functions other than as intended (AHRQ, 2009). Significance and Consequences The hospitals are forced to foot the bills of costs acquired from HACs and Never Events and that pose a great liability on them to limit their occurrence. The hospitals are also prohibited from passing such charges onto the patients.

Some states have enacted legislation requiring reporting of incidents on the NQF list. For example, in 2003, the Minnesota legislature, with strong support from the state hospital association, was the first to pass a statute requiring mandatory reporting of “never events”. The law requires hospitals to investigate each event, report its underlying cause, and take corrective action to prevent similar events (CMS, 2006). Furthermore, the rate of occurrence can also be reduced and predetermined through accurate treatment and proper documentation of underlying pre-existing conditions.

The use of surgical checklists, clear language and understanding the policies and publications of difference between the NQF “never events” and CMS “non-reimbursable serious hospital acquired-conditions” to avoid claims of negligence (Lembitz & Clarke, 2009). Nursing Strategies to Reduce Occurrences Nurses and other health care providers should be aware of safety measures that would help to reduce the occurrences of HACs and Never Events when taking care of patients. Health workers should be able to detect the means for transmitting such diseases and be able to track risky conditions from the onset.

For instance, in order to prevent a fall, the nurse should be able to notice immediately the patient is beginning to move in a high risk manner. Prevention is better than cure. The nurse should instantly detect when the patient is beginning to get out of bed or chair (Dalcon, 2010). It is important for healthcare facilities to follow the universal protocols to reduce wrong site/wrong patient surgery. It is also important that healthcare facilities adhere to NQF guidelines of preventable measures and the use of standards that will improve the utmost quality of care for patients.

The Significance of Documentation The heightened concern about HACs makes it imperative that all pre-existing conditions are documented on the admission of a patient. Thorough assessment should be made upon admission such as performing a thorough skin assessment on admission. Present on admission is defined as present at the time the order for in patient admission occurs. Any condition, including a pressure ulcer, developed during a previous hospital stay, at home or in long-term care facility should be documented (Dalcon, 2010).

Conclusion In an Ideal world ‘Never Events should never happen but unfortunately mistakes do happen. HACs and Never Events are preventable; therefore their existence in the hospital setting should be reduced to the minimal if not completely eliminated. The use of broad-based resources, re-examination of protocols and staff retraining are great measures for reducing the occurrence of hospital acquired conditions and Never Events (AHRQ, 2009). References AHRQ Patient Safety Network (2009). “Never Events. ”

Retrieved from http://www. psnet.ahrq. gov/primer. aspx? primerID=3 Centers for Medicare and Medicaid Services. (2006). “Press release: Eliminating Serious, Preventable and Costly Medical Errors – Never Events. ” Retrieved from www. cms. hhs. gov/apps/media/press/release. asp? Counter=1863 Dalcon. (2010). “Never Events and HACs” Dalcon Communications. Retrieved from http://www. dalcon. com/healthcare/dalcon-alert/never-events-and-hacs/ Lembitz, A. , & Clarke, T. (2009). “Clarifying ‘Never ‘Events’ and Introducing ‘Always Events’. ” Patient Safety in Surgery. 3(26).

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