Never Events in Healthcare

Never Events in Healthcare

Introduction

Health is the basic right of every individual. The primary aim of healthcare units and professionals is provision of quality healthcare services in a safe environment that ensures safety of the patient and healthcare provider too. In order to guarantee that healthcare services are provided safely and the patients are protected, the National Quality Forum has devised a list of Serious Reportable Events also known as Never Events in Healthcare. Every year these events are a cause of 90,000 deaths and $5.7 billion in added healthcare costs. Costs pertaining to areas other than medical harm are around $29 billion a year. This includes disability, job losses and low productivity (NQF, SRE Facts sheet December 2011).

Discussion

Background

The National Quality Forum is a not for profit organization that works to make sure the provision of quality healthcare. It comprises of the physicians, hospitals and policy setters, who strive to build national agreement on goals and targets for better healthcare performance. The term “Never Events” was first coined by Ken Kizer, ex-CEO of the National Quality Forum. This term refers to significantly adverse events that may end up in serious calamities. Since these events are preventable, they needed to be identified and endorsed. Initially a list of 27 events was established in 2002. The National Quality Forum revised and updated the list in their report of 2011.

This list does not cover all the adverse incidents occurring in the healthcare unit. In fact this list comprises of events that can be matter of concern to the patient and healthcare provider, recognizable and avoidable too. These can be grouped into 7 categories: surgical or invasive procedure events, product or device events, patient protection events, care management events, environmental events, radiological events and criminal events (NQF, 2011).

Surgical or Invasive Procedure Events

Surgical or Invasive Procedures are critical in the sense that they can lead to serious consequences in case of any minor errors. These events include surgery performed on the wrong site or on the wrong patient, wrong procedure performed on a patient, mistakenly leaving a foreign object after surgical procedure and intraoperative or immediately postoperative/post procedure death in an ASA Class 1 patient.

Product or Device Events

These events include any harm or health risk proposed to the patient by using infected drugs or any such devices present in the healthcare unit, any serious injury resulting by the unprofessional use of any device i.e. using it for the other function for which it was made. These events also include air embolism developed in a patient during his/her stay in the hospital under care.

Patient Protection Events

It is the responsibility of healthcare units to safeguard its patients and any sort of failure may lead to this group of 'Never Events'. These include discharging a patient either a child or an adult of altered mental status to any unauthorized person, any harm associated with patient's disappearance or any attempt of suicide or self-mutilation during patient's stay in the ...