It is critical that as a nurse, you use evidence-based protocols to provide safe patient care and minimize or avoid the occurrence of “never events,” or medical errors that should never occur. We’ve created the Never Events Collections below to help you understand best practices to maximize patient safety and help you meet your continuing education needs. More...
There are currently 29 never events recognized by the National Quality Forum (NQF), defined as “errors in medical care that are of concern to both the public and health care professionals and providers, clearly identifiable and measurable (and thus feasible to include in a reporting system), and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the health care organization.”
In 2008, the Centers for Medicare and Medicaid Services (CMS) adopted a non-reimbursement policy for certain never events. This list of “non-reimbursable serious hospital-acquired conditions” was created to motivate hospitals to implement standardized protocols to improve patient safety. These are never events that are deemed "reasonably preventable" through the use of evidence-based guidelines. It is important to note that while lack of reimbursement is the biggest issue for hospitals, never events are also publicly reported. So, hospitals are not getting paid and the public is learning about preventable, and often catastrophic, conditions when they occur.
The following are never events that are not reimbursable by Medicare:
- Pressure ulcer stages III and IV
- Falls and trauma
- Surgical site infection after bariatric surgery for obesity, certain orthopedic procedures, and bypass surgery (mediastinitis)
- Vascular-catheter associated infection
- Catheter-associated urinary tract infection
- Administration of incompatible blood
- Air embolism
- Foreign object unintentionally retained after surgery
- Certain manifestations of poor glycemic control
- Deep vein thromboses and pulmonary emboli associated with hip and knee replacements.