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Never Events & their Management

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Gowri Shankar
Gowri Shankar

never events are events which should never occur in medical practice.this ppt throws lights few commons never evnts and guidelines to prevent them.

Health & Medicine
1 of 29
“Never Events” & their Management Speaker- Dr Gowri Shankar B Moderator- Dr Sailaja K
Over view… Introduction History Definition What are they.. Anaesthesia perspective.. How to tackle… How to prevent..
“Never Events” - History In 1999, IOM’s published To Err Is Human, called for a nationwide public mandatory reporting system to identify and learn from medial errors. The term "Never Event" ,2001 by Ken Kizer, National Quality Forum (NQF), in reference to particularly shocking medical errors.
“Never Events” - History • The National Quality Forum (NQF) ,1999 - established in the United States in 1999 as a nonprofit, patient advocacy group. • Aim to improve the quality of healthcare in the US, by developing and implementing a national quality measurement and reporting system. • In 2002, it produced a list of 27 ‘Serious Reportable Events’ (SRE) under 6 categories with further updates in 2006 and 2011
“Never Events” - History In 2008, US Centers for Medicare and Medicaid Services adopted a list of 10 hospital acquired conditions from the original list, officially referred to as never events. same year in the UK, Lord Darzi published ‘High-quality care for all: NHS Next Stage Review’ proposed the introduction of a similar initiative for the NHS in England. The National Patient Safety Agency(NPSA) in 2010 launched the Never Event Framework and drew up a core list consisting of eight events, later revised.
“Never Events” - definition ‘‘Serious, largely preventable patient safety incidents that should not occur if relevant preventive measures have been put in place.” Never events are the "kind of mistake” that should “never happen" in the field of medical treatment. Leapfrog Group – “adverse events that are serious, largely preventable, and of concern to both the public and healthcare providers for the purpose of public accountability.”
What are they… 1 • SURGICAL OR INVASIVE PROCEDURE EVENTS 2 • PRODUCT OR DEVICE EVENTS 3 • PATIENT PROTECTION EVENTS 4 • CARE MANAGEMENT EVENTS 5 • ENVIRONMENTAL EVENTS 6 • RADIOLOGIC EVENTS 7 • POTENTIAL CRIMINAL EVENTS
SURGICAL OR INVASIVE PROCEDURE EVENTS 1A. Surgery or other invasive procedure performed on the wrong site 1B. Surgery or other invasive procedure performed on the wrong patient 1C. Wrong surgical or other invasive procedure performed on a patient 1D. Unintended retention of a foreign object in a patient after surgery or other invasive procedure 1E. Intraoperative or immediately postoperative/death in an ASA Class 1 patient
PRODUCT OR DEVICE EVENTS • 2A. Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting. • 2B. Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended. • 2C. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting.
PATIENT PROTECTION EVENTS 3A. Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person 3B. Patient death or serious injury associated with patient elopement (disappearance) 3C. Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting
CARE MANAGEMENT EVENTS 4A. Patient death or serious injury associated with a medication error 4B. Patient death or serious injury associated with unsafe administration of blood products 4C. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting 4D. Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy (new)
4E. Patient death or serious injury associated with a fall while being cared for in a healthcare setting 4F. Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission to a healthcare setting 4G. Artificial insemination with the wrong donor sperm or wrong egg 4H. Patient death or serious injury resulting from the (new) irretrievable loss of an irreplaceable biological specimen 4I. Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results (new) CARE MANAGEMENT EVENTS
ENVIRONMENTAL EVENTS 5A. Patient or staff death or serious injury associated with an electric shock 5B. Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or are contaminated by toxic substances 5C. Patient or staff death or serious injury associated with a burn incurred from any source 5D. Patient death or serious injury associated with the use of physical restraints or bedrails
RADIOLOGIC EVENTS 6A. Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area (new)
POTENTIAL CRIMINAL EVENTS 7A. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider 7B. Abduction of a patient/resident of any age 7C. Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting 7D. Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting
Anaesthesia perspective…..
Anaesthesia perspective…..
How common…!!
What are we worried ABOUT .. • Breaking Bad News • Damage to reputation • Facing questions of relatives • Fear of mob violence • Handling police enquiry • Medico-legal issues – arrest, courts, case, judgment… • Compensation amount • Loss of confidence • Stress in future cases
How to tackle a never event…
How to tackle a never event… The Leapfrog Group is a nonprofit quality-improvement organization whose members work to improve regulations surrounding the quality and safety of American healthcare. According to the Leapfrog Group, hospitals commit to follow 4 steps: 1) Apologize to the patient 2) Report the event 3) Perform a root cause analysis 4) Waive costs directly related to the event.
How to prevent… • Every Never event - existing guidelines for their prevention. • Safety culture with strong clinical leadership. • Adoption of design and technological solutions. • Meticulous and conscientious use of checklists .
“ W.H.O.” Surgical Safety
Thank you….!! “…there are some patients we cannot help, there are none we cannot harm...” Dr ken stahl
References .. 1. National quality forum https://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx 2. Siddharth S Adyanthaya, Vishal Patil; Never events: an anaesthetic perspective, Continuing Education in Anaesthesia Critical Care & Pain, Volume 14, Issue 5, 1 October 2014, page 197- 201 https://doi.org/10.1093/bjaceaccp/mkt055 3. https://businesstoday.co.ke/10-shocking-cases-wrong-patient- surgeries/ 4. Chapter 9: How hospitals can be made safer- How to make sure “never “ events never occur thebestmedicalcare.com/patient-safety/how-hospitals-can-be- made.html 5. https://www.who.int/patientsafety/safesurgery/checklist/en/ 6. https://mohfw.gov.in/sites/default/files/national%20patient %20safety%20implimentation_for%20web.pdf
Never Events & their Management
Never Events & their Management

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Never Events & their Management

  • 1. “Never Events” & their Management Speaker- Dr Gowri Shankar B Moderator- Dr Sailaja K
  • 2. Over view… Introduction History Definition What are they.. Anaesthesia perspective.. How to tackle… How to prevent..
  • 3.
  • 4. “Never Events” - History In 1999, IOM’s published To Err Is Human, called for a nationwide public mandatory reporting system to identify and learn from medial errors. The term "Never Event" ,2001 by Ken Kizer, National Quality Forum (NQF), in reference to particularly shocking medical errors.
  • 5. “Never Events” - History • The National Quality Forum (NQF) ,1999 - established in the United States in 1999 as a nonprofit, patient advocacy group. • Aim to improve the quality of healthcare in the US, by developing and implementing a national quality measurement and reporting system. • In 2002, it produced a list of 27 ‘Serious Reportable Events’ (SRE) under 6 categories with further updates in 2006 and 2011
  • 6. “Never Events” - History In 2008, US Centers for Medicare and Medicaid Services adopted a list of 10 hospital acquired conditions from the original list, officially referred to as never events. same year in the UK, Lord Darzi published ‘High-quality care for all: NHS Next Stage Review’ proposed the introduction of a similar initiative for the NHS in England. The National Patient Safety Agency(NPSA) in 2010 launched the Never Event Framework and drew up a core list consisting of eight events, later revised.
  • 7. “Never Events” - definition ‘‘Serious, largely preventable patient safety incidents that should not occur if relevant preventive measures have been put in place.” Never events are the "kind of mistake” that should “never happen" in the field of medical treatment. Leapfrog Group – “adverse events that are serious, largely preventable, and of concern to both the public and healthcare providers for the purpose of public accountability.”
  • 8. What are they… 1 • SURGICAL OR INVASIVE PROCEDURE EVENTS 2 • PRODUCT OR DEVICE EVENTS 3 • PATIENT PROTECTION EVENTS 4 • CARE MANAGEMENT EVENTS 5 • ENVIRONMENTAL EVENTS 6 • RADIOLOGIC EVENTS 7 • POTENTIAL CRIMINAL EVENTS
  • 9. SURGICAL OR INVASIVE PROCEDURE EVENTS 1A. Surgery or other invasive procedure performed on the wrong site 1B. Surgery or other invasive procedure performed on the wrong patient 1C. Wrong surgical or other invasive procedure performed on a patient 1D. Unintended retention of a foreign object in a patient after surgery or other invasive procedure 1E. Intraoperative or immediately postoperative/death in an ASA Class 1 patient
  • 10. PRODUCT OR DEVICE EVENTS • 2A. Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting. • 2B. Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended. • 2C. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting.
  • 11. PATIENT PROTECTION EVENTS 3A. Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person 3B. Patient death or serious injury associated with patient elopement (disappearance) 3C. Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting
  • 12. CARE MANAGEMENT EVENTS 4A. Patient death or serious injury associated with a medication error 4B. Patient death or serious injury associated with unsafe administration of blood products 4C. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting 4D. Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy (new)
  • 13. 4E. Patient death or serious injury associated with a fall while being cared for in a healthcare setting 4F. Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission to a healthcare setting 4G. Artificial insemination with the wrong donor sperm or wrong egg 4H. Patient death or serious injury resulting from the (new) irretrievable loss of an irreplaceable biological specimen 4I. Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results (new) CARE MANAGEMENT EVENTS
  • 14. ENVIRONMENTAL EVENTS 5A. Patient or staff death or serious injury associated with an electric shock 5B. Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or are contaminated by toxic substances 5C. Patient or staff death or serious injury associated with a burn incurred from any source 5D. Patient death or serious injury associated with the use of physical restraints or bedrails
  • 15. RADIOLOGIC EVENTS 6A. Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area (new)
  • 16. POTENTIAL CRIMINAL EVENTS 7A. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider 7B. Abduction of a patient/resident of any age 7C. Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting 7D. Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting
  • 20. What are we worried ABOUT .. • Breaking Bad News • Damage to reputation • Facing questions of relatives • Fear of mob violence • Handling police enquiry • Medico-legal issues – arrest, courts, case, judgment… • Compensation amount • Loss of confidence • Stress in future cases
  • 21. How to tackle a never event…
  • 22. How to tackle a never event… The Leapfrog Group is a nonprofit quality-improvement organization whose members work to improve regulations surrounding the quality and safety of American healthcare. According to the Leapfrog Group, hospitals commit to follow 4 steps: 1) Apologize to the patient 2) Report the event 3) Perform a root cause analysis 4) Waive costs directly related to the event.
  • 23. How to prevent… • Every Never event - existing guidelines for their prevention. • Safety culture with strong clinical leadership. • Adoption of design and technological solutions. • Meticulous and conscientious use of checklists .
  • 25.
  • 26. Thank you….!! “…there are some patients we cannot help, there are none we cannot harm...” Dr ken stahl
  • 27. References .. 1. National quality forum https://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx 2. Siddharth S Adyanthaya, Vishal Patil; Never events: an anaesthetic perspective, Continuing Education in Anaesthesia Critical Care & Pain, Volume 14, Issue 5, 1 October 2014, page 197- 201 https://doi.org/10.1093/bjaceaccp/mkt055 3. https://businesstoday.co.ke/10-shocking-cases-wrong-patient- surgeries/ 4. Chapter 9: How hospitals can be made safer- How to make sure “never “ events never occur thebestmedicalcare.com/patient-safety/how-hospitals-can-be- made.html 5. https://www.who.int/patientsafety/safesurgery/checklist/en/ 6. https://mohfw.gov.in/sites/default/files/national%20patient %20safety%20implimentation_for%20web.pdf

Editor's Notes

  1. IOM’s 1999,  To  Err  Is  Human,   called  for  a  nationwide  public mandatory  reporting  system  to   identify  and  learn  from  medical  errors.     • The  term  "Never  Event"  was  first   introduced  in  2001  by  Ken  Kizer,  MD,   former  CEO  of  the  National  Quality   Forum  (NQF),  in  reference  to   particularly  shocking  medical  errors. Before  the  IOM  reports,  medical  errors   were  generally  considered  acceptable   consequences  of  care  and  remained   deeply  hidden
  2. •  The National Quality Forum (NQF) was created in 1999 by a coalition of public-and private-sector leaders in response to the recommendation of the Advisory Commission on Consumer Protection and Quality in the Health Care Industry. •  The NQF is a nonprofit organization that aims to improve the quality of healthcare in the United States. •  The primary aim of the NQF is to improve healthcare by developing and implementing a national quality measurement and reporting system. •  In 2002, the NQF created a list of 27 “Serious Reportable Events” (SRE’s) which is the term the NQF uses for “Never Events”. Today the list contains 29 SRE’s
  3. In 2008, with the primary aim of increasing awareness of the quality agenda the US Centers for Medicare and Medicaid Services adopted a list of 10 hospital acquired conditions from the original list of SRE, which they officially referred to as never events. They subsequently introduced a
  4. According to the Leapfrog Group never events are defined as adverse events that are serious, largely preventable, and of concern to both the public and healthcare providers for the purpose of public accountability.
  5. Nqfs list SRE wer divided into 7 categories..
  6. (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)
  7. These graph grossly depicts lesser number than actual…becoz poor reporting or non reporting ..but why so what are we worried about..
  8. According to the Leapfrog Group never events are defined as adverse events that are serious, largely preventable, and of concern to both the public and healthcare providers for the purpose of public accountability.
  9. NHS.. Hospital should maintain a never event registry..
  10. Universal protocol for preventing wrong side ,wrong procedure, and wrong person (Joint Commission ,2009) 1. Preprocedural verification of all relevant documents