1. 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.. 1

2.  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” “Never Events” Eli Grambling, Andre Nakamura, Julia Barbosa2

3.  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.  http://www.pssjournal.com/content/3/1/26/table/T1 “Never Events” - NQF Eli Grambling, Andre Nakamura, Julia Barbosa3

4.  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.  http://www.pssjournal.com/content/3/1/26/figure/F1 “Never Events” - CMS Eli Grambling, Andre Nakamura, Julia Barbosa4

5.  Examples of Liability Concerns and Negligence Claims 1)Prevention of Falls 2)Postoperative infections and thromboembolic events “Never Events” - CMS Eli Grambling, Andre Nakamura, Julia Barbosa5

6.  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 Strategies To Reduce Risk Eli Grambling, Andre Nakamura, Julia Barbosa6

7.  Always events as opposed to never events bring a positive connotation rather than the negative connotation associated with never events “Always Events” Eli Grambling, Andre Nakamura, Julia Barbosa7

8.  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 “Always Events” Eli Grambling, Andre Nakamura, Julia Barbosa8

9.  Lembitz, Alan, and Ted Clarke. "Clarifying "never Events" and Introducing "always Events"" Patient Safety in Surgery. 31 Dec. 2009. Web. 11 Feb. 2015.. Source Eli Grambling, Andre Nakamura, Julia Barbosa9

10. Questions? Eli Grambling, Andre Nakamura, Julia Barbosa10