The “Never Events” Policy
Executive Summary
Protecting all patients from avoidable medical errors or harms is universal agreement, How it achieve this is often very complex (National Patient Safety Agency [NHS], 2012). With “Never Event” policy, clearly defined the most processes and procedures that’s needed for patients to help ensure that these incidents do not happen and keep patient safe (NHS, 2010).
Although the occurrence of the “Never Events” is easily recognized and clearly defined this requirement helps minimize conflict around who makes error, and ensures focus on learning and improving patient safety, In addition the rationale behind a type of serious incident being included on the ““Never Events” s” list is that there are barriers
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Wrong site surgery for example could simply involve a small incision at the beginning of a surgical procedure, Typically, if a member of a surgical team halts the surgery following this error and no serious harm results, the incident is still a wrong site surgery “Never Event” , not a prevented “Never Events” (Mehtsun, Ibrahim, Diener, Pronovost & Makary, 2012). This is because the required checks and procedures cannot have been implemented correctly and the patient still requires further surgery on the correct site (Mehtsun, Ibrahim, Diener, Pronovost and Makary, 2012; I.Moppett & S.Moppett, …show more content…
This will require root cause analysis which will not only examine such issues as compliance with, and the robustness of, relevant processes and procedures but also the role of human factors and how, if possible, these can be mitigated against to reduce the risk of recurrence further. Also it requires vigilance and the need to identify where the risk of a “Never Event” occurring exists before a patient is harmed, so-called prevented “Never Event”. More instructions needed from higher managers to ensure the activation of the quality department which includes risk management part, via more courses and workshops.
All health care providers, managers, leaders and even patients and their families, should work with each other toward creating an environment that helps in improving and promoting patient safety. Managers should establish educating and training programs.
Policy
Chasing Zero is a documentary which was meant to both educate the viewer on the prevalence of medical harm as well as to enlighten both the public and health care providers on the preventability of these events (Discovery, 2010). The documentary expounded on the fact each year more people die each year from a preventable medical error than die due to breast cancer, motor vehicle accidents or AIDS (Institute of Medicine, 1999). Medical harm can result from adverse drug events, surgical injuries, wrong-site surgery, suicides, restraint-related injuries, falls, burns, pressure ulcers and mistaken patient identities (Institute of Medicine, 1999). Incidences of medical error have been reported in the media for many years. The most startling revelation in the documentary is how common medical errors are and how preventable they are.
middle of paper ... ... Root Cause Analysis in Response to a Sentinel Event. Retrieved on March 2014 from world wide web at http://www.pedsanesthesia.org/meetings/2004winter/pdfs/heitmiller_Sentinel.pdf Orlando Regional Healthcare, Education & Development. (2004). Patient Safety: Preventing Medical Errors.
Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities.
Hospital medical errors can involve medicines (e.g., wrong drug, wrong dose, bad combination), an inaccurate or incomplete diagnosis, equipment malfunction, surgical mistakes, or laboratory errors. High medical error rates with serious consequences occurs in intensive care units, operating rooms, and emergency departments; but, serious errors that harmed patients may have prevented or minimized. Understand the nature of the error
Flanagan (1954) defined critical incident as extreme behavior either outstanding effective or ineffective with respect to attaining the general aim of the activity. A critical incident also defined as an unintended event that occurs does not from the patient’s illness but when health services are provided to an individual and resulting serious and undesired events such as death, disability, injury or harm, and lead to prolong hospital stay. “Public Hospitals Act (PHA,2010)”.
The patient safety program in hospital setting is intended to reduce medical errors and hazardous conditions by assuring an environment that inspires error identification, reporting and prevention through education, system enhancement for any adverse occasions such that information about sentinel events that frequently occurs in health care are built in the system progressively for risk reduction. Through education component, proper and effective orientation and training that emphasizes clinical and non-clinical aspects of patient safety, including an inte...
Medical and medication errors and adverse events are well known issues in the health care industry, regardless of country. Errors are either the correct implementation of the wrong procedure or the wrong implementation of the correct procedure (IOM, 1999 pp23-25). Adverse events are considered unintended injuries and/or harm that are caused to the patient but not necessarily due to human error. This proposal will present a technical solution, using case based reasoning, to help prevent the occurrence of errors, thus reduce adverse events, and to make suggestions to the line staff as to what to do when such an event or error happens.
Today, medical error has become a major and important challenge to health care systems across the globe. This is because medical errors often lead to harm that may also be non-repairable (Valiani et al. 540; Denham “Chasing Zero”). In 1999, the Institute of Medicine published a report that indicated that medical error in hospitals accounts for between 48,000 and 98,000 deaths annually (Swift et al. 78; Barger et al. 2441). As such, reducing the occurrence of medical errors has become an international concern. Poorolajal defines a medical error as “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result.” (Poorolajal, et al. para 5 -10). In this case, it’s very important to acknowledge
Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission published their National Patient Safety Goals. Among the goals was the Universal Protocol. The Universal Protocol is actually drawn from several of the National Patient Safety Goals. It relies on multiple check points and the involvement of the entire surgical team to avoid such errors. Wrong site, wrong procedure, and wrong patient surgeries should never happen. The Universal Protocol is an evolving process which reflects the success and failures of healthcare practice, thus it requires periodic updates and policy revisions.
Wu, A. W. (2011). The value of close calls in improving patient safety: Learning how to avoid
One of the most common examples of medical malpractice is wrong-site surgery (WSS). Wrong-site surgery is not only a liability risk, but it is a clinical, financial, and business risk as well. It is also considered a “never event” on the Center for Medicare and Medicaid Services’ list of never events. “The CMS adheres to the NQF definition that never events are (1) errors in medical care that are clearly identifiable and preventable, (2) serious in their consequences for patients, and (3) indicate a real problem in the safety and credibility of a healthcare facility” (Youngberg, 2011). Not only is wrong-site surgery an issue but so is wrong-patient and wrong-procedure.
It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).
(AHRQ, 2017). Despite wrong site surgeries having the aforementioned title of “never events”, such mistakes still occur all too commonly. In fact, one study’s findings reveal that wrong site surgeries happen roughly one in 112,000 procedures, meaning that on average, a single hospital would see such an incident between every five and ten years (Cohen, 2016). Such mistakes, additionally, are not limited to inexperienced medical professionals.
There was a false concept that errors were completely the practitioners fault. Joseph Cafazzo, an associate professor in the University of Toronto’s faculty of medicine who conducts human factors research. “If the user makes an error, it’s usually the result of a design flaw” ( Eggerston 2014). It is important to look at all the factors when looking at safety. These include the interaction between health care professionals, the equipment, employee competency, patient/ practioner interaction,