Specific Examples of “Never Events” and Their Impact

Never Events” & Your Clinical Project

The Centers for Medicare & Medicaid Services (CMS) formed its no-pay policy based on the growing work of National Quality Forum (NQF) of “never events.” Meaning, CMS will no longer pay for certain conditions that result from what might be termed poor practice or events that should never have occurred while a patient was under the care of a healthcare professional.

• Discuss specific examples of “never events” and their impact in your workplace.
• What issues are you considering for your clinical project and why?

Submission Instructions:

• Your initial post should be at least 600 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
• You should respond ( 150 words each) to two of your peers by extending, refuting/correcting, or adding additional nuance to their posts.

“Never events” are serious and preventable medical errors or incidents that should never occur during patient care. These events are typically considered indicators of poor healthcare quality and patient safety. The Centers for Medicare & Medicaid Services (CMS) implemented a no-pay policy for certain “never events” to encourage healthcare providers to improve patient safety and reduce preventable medical errors. Here, I will discuss specific examples of “never events” and their impact in a healthcare workplace, as well as the issues I am considering for my clinical project and why.

Specific Examples of “Never Events” and Their Impact:

1. Wrong-Site Surgery: This occurs when a surgical procedure is performed on the wrong body part, such as the wrong limb or organ. The impact can be devastating for patients, leading to unnecessary pain, disability, and legal repercussions. In my workplace, a wrong-site surgery occurred a few years ago, leading to increased scrutiny, damage to the hospital’s reputation, and potential litigation.
2. Foreign Object Retention: This refers to surgical instruments or other foreign objects being left inside a patient’s body after surgery. It can lead to severe infections, complications, and the need for additional surgeries. In our healthcare facility, a case of foreign object retention led to a CMS investigation, financial penalties, and a focus on improving surgical safety protocols.
3. Medication Errors: Administering the wrong medication, incorrect dosage, or failing to administer necessary medications can result in harm or even death. These errors can occur at various stages, from prescription to administration. In my workplace, a medication error led to a patient’s deterioration and required an extended hospital stay.

Issues for My Clinical Project and Why:

For my clinical project, I am considering addressing the following issues related to “never events”:

1. Enhancing Surgical Safety Protocols: Given the impact of wrong-site surgeries and foreign object retention, I believe that improving surgical safety protocols is crucial. This includes implementing rigorous pre-operative checklists, site verification processes, and measures to prevent objects from being retained in patients. My project will focus on evaluating the effectiveness of these protocols in reducing “never events” in surgical settings.
2. Medication Safety: Medication errors can have serious consequences, and I want to explore ways to enhance medication safety in my healthcare facility. This may involve implementing technology solutions, improving medication reconciliation processes, and providing additional training for healthcare professionals involved in medication administration.
3. Promoting a Culture of Safety: “Never events” often occur due to system failures and communication breakdowns. I plan to develop initiatives to promote a culture of safety within the healthcare organization, encouraging staff to report errors, near misses, and potential safety concerns. This includes education and training on reporting mechanisms and fostering open communication among healthcare teams.
4. Continuous Monitoring and Improvement: My clinical project will also focus on establishing a system for continuous monitoring and improvement. This involves regular audits, root cause analysis of “never events,” and implementing changes based on findings to prevent their recurrence.

In conclusion, “never events” are serious medical errors that should never occur in healthcare settings. These events have a significant impact on patient safety, healthcare organizations, and financial penalties imposed by CMS. For my clinical project, I plan to address issues related to surgical safety, medication safety, and promoting a culture of safety to reduce the occurrence of “never events” in my workplace and ultimately improve patient care and outcomes.