In an effort to improve the quality of health care and to reduce the rate of “never events,” in May 2006 the Centers for Medicare and Medicaid Services (CMS) reported an initiative to decline payments for “never events.” The National Quality Forum (NQF) defines “never events” 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.”1 The NQF listed 29 never events, which include surgeries performed on wrong body parts; surgeries performed on wrong patients; medication errors; pressure ulcers acquired after admission; hospital-acquired infections; and patient death associated with patient elopement.
Implementing methods to prevent or reduce the occurrence of never events could pose some challenges, but may be beneficial in the long term. Such implementations could include revising systematic work methods. For example, a systematic work method could include mandating the documentation of pre-existing conditions to ensure that hospitals are not blamed, and consequently denied payment, for certain conditions. Another example would be to require documentation and date-stamped photographs of decubitis ulcers upon a patient’s admission. Assessing and documenting signs and symptoms of potential problems would also be prudent.
Employing methods to prevent or reduce the occurrence of never events could pose challenges, including more paperwork for practitioners and hiring additional personnel. However, they would be beneficial by reducing the frequency of never events and avoiding the denial of payments by CMS.