1. Never Events vs. Always Events Eli Grambling

2. “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”

3. “Never Events” - NQF  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 Table 1.

4. “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” Figure 1.

5. “Never Events” - CMS  Examples of Liability Concerns and Negligence Claims 1) Prevention of Falls 2) Postoperative infections and thromboembolic events

6. 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

7. “Always Events”  Always events as opposed to never events bring a positive connotation rather than the negative connotation associated with never events

8. “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

9. Source  http://www.pssjournal.com/content/3/1/26