It's Now or Never: Resources to Ensure that Never Events Never Happen

Page last updated on December 23 at 1:59 PM.

Have a question about Never Events? Or a prevention strategy that you’d like to share?  
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Please click on any of the images below to view the related video on each topic.

Never Events Coaching includes:

• Organizational assessment
• Presentation of findings and action plan
• Detailed report that identifies opportunities for cost avoidance
• Sequenced approach of Evidence-Based LeadershipSM tools and tactics to reduce and prevent Never Events
• Leadership Development Institute speakers on topics related to patient safety and the prevention of Never Events

For more information on Never Events Coaching, contact Julie O'Shaughnessy at julie.oshaughnessy@studergroup.com.

Overview

Studer Group is committed to help organizations achieve a culture of always, where individuals do the right things for every patient, every time. This requires individual accountability across an organization. The result is individual actions that always provide evidence-based care and compassion . . . and never do harm.

The focus of this page of resources is to help healthcare providers eliminate the 14 types of medical errors that CMS consider to be "hospital-acquired conditions." By definition these are considered by CMS to be preventable; high cost or high volume (or both); and result in additional costs. Beginning October 1, 2008, hospitals will not receive additional payment by CMS when these conditions were not present on admission. Instead, they will be paid as if the secondary diagnosis wasn't present.

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Studer Group's research team has identified several external sources that you may find helpful as you seek to eliminate these events. You can access the latest evidence and case studies by following the links below.

Financial Impact

Quint Studer on Financial Crisis' Impact on Healthcare on MSNBC's Morning Joe

Caregivers have always known that their role is to first, do no harm. Now there's also a compelling business case for avoiding preventable medical errors. This update to CMS' reimbursement policy is a small step toward a profound change, as CMS and other payers shift toward Value-Based Purchasing, where reimbursement is based on results rather than activities performed. Below are two charts that show the financial impact of these first 11 conditions that will not be reimbursed beginning October 1, 2008.

Studer Group Resources

• Quality and Safety is the Patient Experience – a visit from Rich Bluni, RN, from Studer Group
• Read "Words that Save - Ensuring that 'never events' never happen" by Rich Bluni, RN and Julie O'Shaughnessy in MHS magazine
• Download a comprehensive slide deck on Never Events.
• Book a national speaker to discuss Never Events at your organization.
• Learn more about Hourly Rounding, a tactic that has been proven to reduce patient falls 50% and pressure ulcers 14%.
• Connect the dots on how certain evidence-based tactics improve both patient safety and patient perception of care.
• Read Quint's blog that offers some quick tips to prevent never events.

Selected National Guidelines and Evidence for Prevention

The following links will take you to resources available on the Internet that describe the related national guidelines, and selected resources that describe prevention strategies. We will keep this site updated as the evidence emerges and invite you to suggest additional resources.

Foreign Object Retained After Surgery

• Evidence-Based Guidelines: Safe Practices for Better Healthcare: A Consensus Report. Summary. The National Quality Forum. August 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nqfpract.htm
• Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment, No. 43. AHRQ Publication No. 01-E058, July 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/ptsafety//chap22.htm
• Cedars-Sinai O.R. - Elimination of Retained Foreign Object Task Force http://www.csmc.edu/11749.html

Air Embolism

• Evidence-Based Guidelines: Safe Practices for Better Healthcare: A Consensus Report. Summary. The National Quality Forum. August 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nqfpract.htm
• Mirski, Marek A. M.D., Ph.D; Lele, Abhijit Vijay M.D; Fitzsimmons, Lunei M.D.; Toung, Thomas J. K. M.D. Diagnosis and Treatment of Vascular Air Embolism. Anesthesiology. 106(1):164-177, January 2007. http://www.anesthesiology.org/pt/re/anes/abstract.00000542-200701000-00026.htm;jsessionid=LYdhVBGxbcrjJzLf9TmY3n2krGCsVMbm2v5XfsnGQkyLhlz8GXJB!1455807198!181195628!8091!-1

Blood Incompatibility

• Evidence-Based Guidelines: Safe Practices for Better Healthcare: A Consensus Report. Summary. The National Quality Forum. August 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nqfpract.htm
• Collette Bishop Hendler, RN, MS, CCRN A Perfect Match: Preventing Blood Incompatibility Errors. http://www.nurse.com/ce/CE481/CoursePage/

Stage III and IV Pressure Ulcers

• Evidence-Based Guidelines:Pressure Ulcers in Adults: Prediction and Prevention. AHCPR Publication No. 92-0047, May 1992. Agency for Healthcare Research and Quality, Rockville, MD http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409

Falls and Trauma

• Evidence-Based Guidelines: Safe Practices for Better Healthcare: A Consensus Report. Summary. The National Quality Forum. August 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nqfpract.htm

Catheter-Associated Urinary Tract Infection

• Evidence-Based Guidelines: Guideline for Prevention of Catheter-associated Urinary Tract Infections. Centers for Disease Control and Prevention. February 1981. Atlanta, GA. http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html

Vascular Catheter-Associated Infection

• Evidence-Based Guidelines: Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2002. Centers for Disease Control and Prevention. September 2005. Atlanta, GA. http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html

Surgical Site Infection (Mediastinitis) after Coronary Artery Bypass Graft

• Evidence-Based Guidelines: Guideline for the Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention. October 2005. Atlanta, GA. http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html

Deep Vein Thrombosis or Pulmonary Embolism Following: Total Knee Replacement, and Hip Replacement

• Evidence-Based Guidelines: Safe Practices for Better Healthcare: A Consensus Report. Summary. The National Quality Forum. August 2003. Agency for Healthcare Research and Quality, Rockville, MD.
• Segal JB, Eng J, Jenckes MW, et al. Diagnosis and Treatment of Deep Venous Thrombosis and Pulmonary Embolism. Evidence Report/Technology Assessment Number 68. (Prepared by Johns Hopkins University Evidence-based Practice Center under Contract No. 290-97-0007.) AHRQ Publication No. 03-E016. Rockville, MD: Agency for Healthcare Research and Quality. March 2003. http://www.ahrq.gov/downloads/pub/evidence/pdf/dvt/dvt.pdf

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