Three key organizations work to define and reduce "never events" - serious medical errors that should never occur. The National Quality Forum creates a list of "Serious Reportable Events" and aims to improve healthcare quality. Some states require mandatory reporting of these events. Hospitals are now incentivized to prevent never events through policies like not providing payment for any costs associated with them. The goal is to learn from mistakes and continuously strengthen patient safety practices.
Reducing Medical Error and increasing patient safety Reducing Medical Error...MedicineAndHealth
Medical errors are common and result in many deaths each year. Around half of adverse events in hospitals are preventable. Errors often occur due to systemic issues rather than individual negligence. To improve patient safety, healthcare systems must be designed with a focus on safety, adopting principles such as encouraging reporting of errors without punishment, and continual learning and improvement from past errors and near misses.
This document discusses competency and error prevention in pharmacy systems. It addresses the importance of training, identifying competency issues, and rectifying them through remedial training or employment action. Both individual and systemic factors that can lead to errors are examined. Hospitals share responsibility for errors and must provide adequate training time and resources to employees. Ongoing education is needed but can be challenging to implement due to budget and resource constraints. Measures must be in place to demonstrate competency and assure quality care.
This document summarizes research on model-based spreadsheet engineering. It discusses (I) automatically inferring models from spreadsheets, (II) embedding models within spreadsheets, and (III) techniques for co-evolving spreadsheet models and data. The goal is to add formal modeling capabilities to spreadsheets to reduce errors and make the evolution of large spreadsheets more manageable.
In this paper we present a quality model for spreadsheets, based on the ISO/IEC 9126 standard that defines a generic quality model for software. To each of the software characteristics defined in the ISO/IEC 9126, we associate an equivalent spreadsheet characteristic. Then, we propose a set of spreadsheet specific metrics to assess the quality of a spreadsheet in each of the defined characteristics. In order to obtain the normal distribution of expected values for a spreadsheet in each of the metrics that we propose, we have executed them against all spreadsheets in the large and widely used EUSES spreadsheet corpus. Then, we quantify each characteristic of our quality model after computing the values of our metrics, and we define quality scores for the different ranges of values. Finally, to automate the atribution of a quality score to a given spreadsheet, according to our quality model, we have integrated the computation of the metrics it includes in both a batch and a web-based tool.
Esta aula sobre Introdução à Segurança do Paciente é uma produção institucional do Centro Colaborador para a Qualidade do Cuidado e Segurança do Paciente (Proqualis) e foi elaborada pelos professores Lucas Zambom, Renata Galotti e Maria Duthil Novaes (FM-USP)
Medical errors represent a serious public health problem and occur frequently in various healthcare settings. They can involve medicines, surgery, diagnosis, equipment, or lab reports. Studies estimate medical errors may be the third leading cause of death in the US, resulting in between 200,000 to 400,000 deaths per year. Many common types of errors like misdiagnosis, unnecessary treatment, medication mistakes, and uncoordinated care have been reduced through standardized protocols and safety practices, but medical errors still frequently harm and kill patients.
This presentation describes the historical basis for error reduction initiatives, published errors and rates of occurrence, prototype paper-based model vs software-based model, software-based model deployment, and results.
This document introduces the concept of patient safety and discusses occurrence variance reporting (OVR) and international patient safety goals. It notes that medical errors injure 1 in 25 hospital patients and kill 44,000-98,000 people per year in the US. The goals of patient safety are to detect safety issues, implement preventive actions, and reduce risks. OVR involves voluntary reporting of process variations to improve quality and prevent recurrences. It identifies adverse events, near misses, and sentinel events. The six international patient safety goals focus on correctly identifying patients, improving communication, increasing medication safety, ensuring correct surgical procedures, reducing healthcare-associated infections, and decreasing falls.
Reducing Medical Error and increasing patient safety Reducing Medical Error...MedicineAndHealth
Medical errors are common and result in many deaths each year. Around half of adverse events in hospitals are preventable. Errors often occur due to systemic issues rather than individual negligence. To improve patient safety, healthcare systems must be designed with a focus on safety, adopting principles such as encouraging reporting of errors without punishment, and continual learning and improvement from past errors and near misses.
This document discusses competency and error prevention in pharmacy systems. It addresses the importance of training, identifying competency issues, and rectifying them through remedial training or employment action. Both individual and systemic factors that can lead to errors are examined. Hospitals share responsibility for errors and must provide adequate training time and resources to employees. Ongoing education is needed but can be challenging to implement due to budget and resource constraints. Measures must be in place to demonstrate competency and assure quality care.
This document summarizes research on model-based spreadsheet engineering. It discusses (I) automatically inferring models from spreadsheets, (II) embedding models within spreadsheets, and (III) techniques for co-evolving spreadsheet models and data. The goal is to add formal modeling capabilities to spreadsheets to reduce errors and make the evolution of large spreadsheets more manageable.
In this paper we present a quality model for spreadsheets, based on the ISO/IEC 9126 standard that defines a generic quality model for software. To each of the software characteristics defined in the ISO/IEC 9126, we associate an equivalent spreadsheet characteristic. Then, we propose a set of spreadsheet specific metrics to assess the quality of a spreadsheet in each of the defined characteristics. In order to obtain the normal distribution of expected values for a spreadsheet in each of the metrics that we propose, we have executed them against all spreadsheets in the large and widely used EUSES spreadsheet corpus. Then, we quantify each characteristic of our quality model after computing the values of our metrics, and we define quality scores for the different ranges of values. Finally, to automate the atribution of a quality score to a given spreadsheet, according to our quality model, we have integrated the computation of the metrics it includes in both a batch and a web-based tool.
Esta aula sobre Introdução à Segurança do Paciente é uma produção institucional do Centro Colaborador para a Qualidade do Cuidado e Segurança do Paciente (Proqualis) e foi elaborada pelos professores Lucas Zambom, Renata Galotti e Maria Duthil Novaes (FM-USP)
Medical errors represent a serious public health problem and occur frequently in various healthcare settings. They can involve medicines, surgery, diagnosis, equipment, or lab reports. Studies estimate medical errors may be the third leading cause of death in the US, resulting in between 200,000 to 400,000 deaths per year. Many common types of errors like misdiagnosis, unnecessary treatment, medication mistakes, and uncoordinated care have been reduced through standardized protocols and safety practices, but medical errors still frequently harm and kill patients.
This presentation describes the historical basis for error reduction initiatives, published errors and rates of occurrence, prototype paper-based model vs software-based model, software-based model deployment, and results.
This document introduces the concept of patient safety and discusses occurrence variance reporting (OVR) and international patient safety goals. It notes that medical errors injure 1 in 25 hospital patients and kill 44,000-98,000 people per year in the US. The goals of patient safety are to detect safety issues, implement preventive actions, and reduce risks. OVR involves voluntary reporting of process variations to improve quality and prevent recurrences. It identifies adverse events, near misses, and sentinel events. The six international patient safety goals focus on correctly identifying patients, improving communication, increasing medication safety, ensuring correct surgical procedures, reducing healthcare-associated infections, and decreasing falls.
The document discusses various ways hospitals can improve patient safety and reduce medical errors in areas such as surgery, medication administration, infections, and diagnosis. It provides examples of how hospitals have successfully reduced errors rates in these areas through methods like checklists, standardized processes, computerized order entry, barcoding, and visual aids. Overall, the document advocates for applying lean problem solving methods to identify and address the root causes of common medical mistakes and adverse events.
Covid Vaccines and Cardiovascular Adverse Events: Is there a link?MfonAmana1
This document explores cardiovascular issues reported after receiving the COVID-19 vaccine using data from the VAERS database. It finds that females and those aged 50-69 experienced the most heart-related adverse events. Certain Pfizer, Moderna, and Janssen vaccine lots starting with specific codes saw higher reports of issues like tachycardia, arrhythmias and myocarditis. The author acknowledges limitations like underreporting but aims to objectively analyze available data on potential vaccine side effects.
Medical errors pose a significant burden globally. While they occur most commonly in hospitals and psychiatric units, with wrong-site surgery being the most frequent issue, they are a preventable ongoing problem. Effective prevention requires multiple coordinated solutions and systems that focus on continually learning from past mistakes, rather than blame, in order to reduce future risks and harm to patients.
Unit-V Health information system MHA II Semester.pptxanjalatchi
This document discusses health informatics systems. It defines health informatics as the intersection of information science, computer science, and healthcare. The document outlines the objectives, requirements, components, sources, uses, and applications of health informatics. It discusses collecting and processing health-related data and information to organize healthcare services and conduct research. Some key benefits of health informatics systems include centralized data, increased efficiency, and improved security and access to patient information.
The document outlines the International Patient Safety Goals (IPSG) which are aimed at reducing common causes of medical errors and improving patient safety. It discusses the goals of correctly identifying patients, improving communication effectiveness, improving safety of high-alert medications, ensuring correct surgery procedures, reducing healthcare-associated infections, and reducing risks of patient harm from falls. For each goal, it provides more details on the specific processes and standards involved in achieving that goal.
The Potential Use of Mobile and Wearable Sensor Devices in the Management of ...Tim Delany
As the rate of information technology increases at an exponential rate, more and more devices and sensors which are capable of harnessing crucial data (such as vital signs) are being integrated into the healthcare ecosystem. The benefit of mobile technologies to intervene and improve health is increasingly becoming a topic of discussion. Through the use of examples from three primary chronic conditions, this report will critically analyse the scientific findings of the use of these sensors and the possible impact they might have on future diagnoses and improving the overall efficiency and accuracy of healthcare management. This report will specifically interrogate the multiple technologies which can be integrated for cardiovascular problems, diabetes and chronic obstructive pulmonary disorder. The overall findings concluded that these novel technologies would provide considerable improvements to healthcare, but would have to overcome several obstacles prior to total integration. A cost-benefit analysis would have to be done to overcome the previous more traditional approach.
Babithas Notes on unit-5 Health/Nursing Informatics TechnologyBabitha Devu
The document discusses patient safety in healthcare. It provides definitions of patient safety and discusses some key facts:
- An estimated 134 million adverse events worldwide result in 2.6 million deaths annually, especially in low- and middle-income countries. Medical errors are among the most common adverse events.
- Investments in patient safety can improve outcomes and save costs by preventing unnecessary harm and treatment expenditures.
- Common adverse events include medication errors, healthcare-associated infections, surgical complications, diagnostic errors, and radiation errors.
- Patient safety is enhanced through risk management, which identifies risks, analyzes their causes and impacts, evaluates their severity, and develops treatment plans to control, transfer, or avoid risks.
In the presentation, a summary of initiatives to be taken by hospitals in different areas for patient safety have been described for the knowledge, practices and implementation of patient safety initiative by hospital managers/Administrators.
Patient safety Incident (PSI) is an unplanned or unintended event or circumstance that could have resulted or did result in harm to a patient while in the care of a health facility. In this presentation, I explored the concepts of patient safety and patient safety incidents. I also explored the concept of Reporting systems, properly now known as reporting and learning systems - because learning is paramount in the reporting system. I focused on the minimal information model, which is more routinely used compared to the intermediate and full information models.
Krish Sankaranarayanan has over 24 years of experience in healthcare and holds multiple degrees including an MS in Patient Safety Leadership. He discussed the historical context of patient safety including figures like Florence Nightingale and Dr. Codman who helped establish standards. High reliability organizations have zero tolerance for errors, unlike healthcare which has error rates comparable to less safe industries. Common causes of medical errors include miscommunication and lack of standardized processes. The presentation provided tools and techniques to improve safety including accreditation, checklists, and focusing on system design rather than individual blame.
This document discusses patient safety in healthcare. It defines patient safety as the absence of preventable harm during healthcare. It notes that most patient harm is due to systemic flaws rather than individual negligence. It then discusses various types of patient safety concerns like medical errors, adverse events, infections, and falls. International patient safety goals are also presented, such as properly identifying patients, improving communication, and reducing healthcare-associated infections. The document emphasizes that improving safety requires efforts across many areas to protect patients from harm.
This document discusses policy options for reducing adverse surgical outcomes in Illinois. It summarizes the research showing that surgical safety checklists can reduce complications rates by up to 57% and mortality rates by up to 25%. Checklists improve communication and teamwork in the operating room. The document proposes amending Illinois' Hospital Licensing Act to mandate checklist use in hospitals and require circulating nurses to oversee checklist completion. Hospitals would also form patient safety committees including providers and administrators to promote checklist compliance. Evaluating this policy change could help reduce Illinois' annual $14.3 million costs from preventable surgical complications.
This document discusses the costs of medical errors and efforts to reduce preventable hospital-acquired conditions (HACs). It notes that medical errors may cause up to 98,000 deaths per year costing up to $29 billion annually. Hospitals have little incentive to improve safety due to externalizing most error costs. In response, policies began denying Medicare/Medicaid payments for treatments from certain HACs considered preventable. This policy was expanded in 2012/2015 and may reduce payments to hospitals with the highest rates of HACs. The goal is to incentivize greater patient safety.
This document discusses lessons that can be learned from international healthcare systems to develop a sustainable healthcare system. It provides 3 key lessons:
1. Prioritize health in policymaking by demonstrating how health impacts productivity, education, employment and economic growth.
2. Increase investment in healthcare through dedicated funding and by legislating specific access entitlements.
3. Engage patients by making services patient-centered, ensuring quality communication of information, and driving continuous quality improvement.
The document discusses notifiable diseases, which are diseases that are legally required to be reported to government authorities. It provides information on the process of disease notification and lists examples of notifiable diseases in various countries and within India. It also describes the Integrated Disease Surveillance Programme launched in India in 2004 to help detect and respond rapidly to disease outbreaks. Key agencies involved in disease surveillance and reporting at national and international levels are also outlined.
Introducing Comprehensive, Concurrent Patient Safety Surveillance for Hospita...Health Catalyst
Health Catalyst is excited to announce the Patient Safety Monitor™ Suite: Surveillance Module, the industry’s first comprehensive patient safety application to use predictive and text analytics combined with concurrent clinician review of data to help monitor, detect, predict and prevent threats to patients before harm can occur.
The Patient Safety Monitor Suite leverages AI and machine learning to quickly identify patterns of harm, learn from those patterns, and suggest strategies to eliminate patient safety risks and hazards. This potent combination of AI, machine learning, text analytics and near real-time data from multiple IT systems enables the Patient Safety Monitor Suite to predict harm events and guide clinical interventions while the patient is still in the hospital.
In this webinar you will learn how the Surveillance Module can provide:
* Greater clarity to the types, numbers, and causes of adverse events, enabling leaders to quickly prioritize improvement efforts.
* Improved patient outcomes such as reduced morbidity, mortality, and length-of-stay, and increased quality-of-life and satisfaction.
* Bottom-line cost savings and improved brand recognition related to unnecessary or preventable high-cost care and reduced/eliminated penalties.
* The ability for clinicians and infection preventionists to focus on patient care instead of burdensome manual data extraction, aggregation, and reporting.
Acs0005 Patient Safety In Surgical Care A Systems Approachmedbookonline
This document discusses patient safety in surgical care from a systems approach. It begins by defining key terms related to patient safety such as adverse events, errors, and preventable events. Several studies are cited that estimate the incidence of adverse events in surgery, finding rates between 3-4% resulting in half being preventable. Common preventable complications included infections, bleeding, and technical errors. Creating a just culture that views errors as systems failures rather than individual faults is important for improving safety.
The document discusses various ways hospitals can improve patient safety and reduce medical errors in areas such as surgery, medication administration, infections, and diagnosis. It provides examples of how hospitals have successfully reduced errors rates in these areas through methods like checklists, standardized processes, computerized order entry, barcoding, and visual aids. Overall, the document advocates for applying lean problem solving methods to identify and address the root causes of common medical mistakes and adverse events.
Covid Vaccines and Cardiovascular Adverse Events: Is there a link?MfonAmana1
This document explores cardiovascular issues reported after receiving the COVID-19 vaccine using data from the VAERS database. It finds that females and those aged 50-69 experienced the most heart-related adverse events. Certain Pfizer, Moderna, and Janssen vaccine lots starting with specific codes saw higher reports of issues like tachycardia, arrhythmias and myocarditis. The author acknowledges limitations like underreporting but aims to objectively analyze available data on potential vaccine side effects.
Medical errors pose a significant burden globally. While they occur most commonly in hospitals and psychiatric units, with wrong-site surgery being the most frequent issue, they are a preventable ongoing problem. Effective prevention requires multiple coordinated solutions and systems that focus on continually learning from past mistakes, rather than blame, in order to reduce future risks and harm to patients.
Unit-V Health information system MHA II Semester.pptxanjalatchi
This document discusses health informatics systems. It defines health informatics as the intersection of information science, computer science, and healthcare. The document outlines the objectives, requirements, components, sources, uses, and applications of health informatics. It discusses collecting and processing health-related data and information to organize healthcare services and conduct research. Some key benefits of health informatics systems include centralized data, increased efficiency, and improved security and access to patient information.
The document outlines the International Patient Safety Goals (IPSG) which are aimed at reducing common causes of medical errors and improving patient safety. It discusses the goals of correctly identifying patients, improving communication effectiveness, improving safety of high-alert medications, ensuring correct surgery procedures, reducing healthcare-associated infections, and reducing risks of patient harm from falls. For each goal, it provides more details on the specific processes and standards involved in achieving that goal.
The Potential Use of Mobile and Wearable Sensor Devices in the Management of ...Tim Delany
As the rate of information technology increases at an exponential rate, more and more devices and sensors which are capable of harnessing crucial data (such as vital signs) are being integrated into the healthcare ecosystem. The benefit of mobile technologies to intervene and improve health is increasingly becoming a topic of discussion. Through the use of examples from three primary chronic conditions, this report will critically analyse the scientific findings of the use of these sensors and the possible impact they might have on future diagnoses and improving the overall efficiency and accuracy of healthcare management. This report will specifically interrogate the multiple technologies which can be integrated for cardiovascular problems, diabetes and chronic obstructive pulmonary disorder. The overall findings concluded that these novel technologies would provide considerable improvements to healthcare, but would have to overcome several obstacles prior to total integration. A cost-benefit analysis would have to be done to overcome the previous more traditional approach.
Babithas Notes on unit-5 Health/Nursing Informatics TechnologyBabitha Devu
The document discusses patient safety in healthcare. It provides definitions of patient safety and discusses some key facts:
- An estimated 134 million adverse events worldwide result in 2.6 million deaths annually, especially in low- and middle-income countries. Medical errors are among the most common adverse events.
- Investments in patient safety can improve outcomes and save costs by preventing unnecessary harm and treatment expenditures.
- Common adverse events include medication errors, healthcare-associated infections, surgical complications, diagnostic errors, and radiation errors.
- Patient safety is enhanced through risk management, which identifies risks, analyzes their causes and impacts, evaluates their severity, and develops treatment plans to control, transfer, or avoid risks.
In the presentation, a summary of initiatives to be taken by hospitals in different areas for patient safety have been described for the knowledge, practices and implementation of patient safety initiative by hospital managers/Administrators.
Patient safety Incident (PSI) is an unplanned or unintended event or circumstance that could have resulted or did result in harm to a patient while in the care of a health facility. In this presentation, I explored the concepts of patient safety and patient safety incidents. I also explored the concept of Reporting systems, properly now known as reporting and learning systems - because learning is paramount in the reporting system. I focused on the minimal information model, which is more routinely used compared to the intermediate and full information models.
Krish Sankaranarayanan has over 24 years of experience in healthcare and holds multiple degrees including an MS in Patient Safety Leadership. He discussed the historical context of patient safety including figures like Florence Nightingale and Dr. Codman who helped establish standards. High reliability organizations have zero tolerance for errors, unlike healthcare which has error rates comparable to less safe industries. Common causes of medical errors include miscommunication and lack of standardized processes. The presentation provided tools and techniques to improve safety including accreditation, checklists, and focusing on system design rather than individual blame.
This document discusses patient safety in healthcare. It defines patient safety as the absence of preventable harm during healthcare. It notes that most patient harm is due to systemic flaws rather than individual negligence. It then discusses various types of patient safety concerns like medical errors, adverse events, infections, and falls. International patient safety goals are also presented, such as properly identifying patients, improving communication, and reducing healthcare-associated infections. The document emphasizes that improving safety requires efforts across many areas to protect patients from harm.
This document discusses policy options for reducing adverse surgical outcomes in Illinois. It summarizes the research showing that surgical safety checklists can reduce complications rates by up to 57% and mortality rates by up to 25%. Checklists improve communication and teamwork in the operating room. The document proposes amending Illinois' Hospital Licensing Act to mandate checklist use in hospitals and require circulating nurses to oversee checklist completion. Hospitals would also form patient safety committees including providers and administrators to promote checklist compliance. Evaluating this policy change could help reduce Illinois' annual $14.3 million costs from preventable surgical complications.
This document discusses the costs of medical errors and efforts to reduce preventable hospital-acquired conditions (HACs). It notes that medical errors may cause up to 98,000 deaths per year costing up to $29 billion annually. Hospitals have little incentive to improve safety due to externalizing most error costs. In response, policies began denying Medicare/Medicaid payments for treatments from certain HACs considered preventable. This policy was expanded in 2012/2015 and may reduce payments to hospitals with the highest rates of HACs. The goal is to incentivize greater patient safety.
This document discusses lessons that can be learned from international healthcare systems to develop a sustainable healthcare system. It provides 3 key lessons:
1. Prioritize health in policymaking by demonstrating how health impacts productivity, education, employment and economic growth.
2. Increase investment in healthcare through dedicated funding and by legislating specific access entitlements.
3. Engage patients by making services patient-centered, ensuring quality communication of information, and driving continuous quality improvement.
The document discusses notifiable diseases, which are diseases that are legally required to be reported to government authorities. It provides information on the process of disease notification and lists examples of notifiable diseases in various countries and within India. It also describes the Integrated Disease Surveillance Programme launched in India in 2004 to help detect and respond rapidly to disease outbreaks. Key agencies involved in disease surveillance and reporting at national and international levels are also outlined.
Introducing Comprehensive, Concurrent Patient Safety Surveillance for Hospita...Health Catalyst
Health Catalyst is excited to announce the Patient Safety Monitor™ Suite: Surveillance Module, the industry’s first comprehensive patient safety application to use predictive and text analytics combined with concurrent clinician review of data to help monitor, detect, predict and prevent threats to patients before harm can occur.
The Patient Safety Monitor Suite leverages AI and machine learning to quickly identify patterns of harm, learn from those patterns, and suggest strategies to eliminate patient safety risks and hazards. This potent combination of AI, machine learning, text analytics and near real-time data from multiple IT systems enables the Patient Safety Monitor Suite to predict harm events and guide clinical interventions while the patient is still in the hospital.
In this webinar you will learn how the Surveillance Module can provide:
* Greater clarity to the types, numbers, and causes of adverse events, enabling leaders to quickly prioritize improvement efforts.
* Improved patient outcomes such as reduced morbidity, mortality, and length-of-stay, and increased quality-of-life and satisfaction.
* Bottom-line cost savings and improved brand recognition related to unnecessary or preventable high-cost care and reduced/eliminated penalties.
* The ability for clinicians and infection preventionists to focus on patient care instead of burdensome manual data extraction, aggregation, and reporting.
Acs0005 Patient Safety In Surgical Care A Systems Approachmedbookonline
This document discusses patient safety in surgical care from a systems approach. It begins by defining key terms related to patient safety such as adverse events, errors, and preventable events. Several studies are cited that estimate the incidence of adverse events in surgery, finding rates between 3-4% resulting in half being preventable. Common preventable complications included infections, bleeding, and technical errors. Creating a just culture that views errors as systems failures rather than individual faults is important for improving safety.
2. • In 2007, 3 different Rhode Island Hospital surgeons
performed 3 wrong-sided brain surgeries.
• Surgeon 1 ignored the nurse and stated he knew which
side of the brain he had to work on… he was wrong.
• Surgeon 2 decided to skip the pre-operative check-list
and cut into the wrong side of the patient’s brain.
• Surgeon 3 just simply began surgery on the wrong side
of the brain.
• 3 enormous medical errors performed during brain
surgery all within one year!
3. In 2001, 99 Fremont, Nebraska cancer patients
were infected with Hepatitis C, the worst
outbreak of it’s kind in America.
Hepatitis C virus (HCV) causes liver
inflammation. The virus is commonly
transmitted when a person comes in close
contact with infected blood, usually by being
stuck with a needle, as in injection drug use,
body piercing, or tattooing.
Nurses under orders from the oncologist Dr.
Tahir Javed, had continuously failed to
change the syringes used on patients.
This story, along with the previous brain
surgery errors, are perfect examples of “Never
Events”.
4. • Never events are the "kind of mistake that should “never
happen" in the field of medical treatment.
• 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. • The
Ins0tute
of
Medicine’s
(IOM’s)
publica0on
in
1999,
To
Err
Is
Human,
called
for
a
na0onwide
public
mandatory
repor0ng
system
to
iden0fy
and
learn
from
medical
errors.
• The
term
"Never
Event"
was
first
introduced
in
2001
by
Ken
Kizer,
MD,
former
CEO
of
the
Na0onal
Quality
Forum
(NQF),
in
reference
to
par0cularly
shocking
medical
errors.
• Before
the
IOM
reports,
medical
errors
were
generally
considered
acceptable
consequences
of
care
and
remained
deeply
hidden.
6. • 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.
7. Surgical
Product
or
Device
Pa0ent
Protec0on
-‐Wrong
Body
Part
-‐Wrong
Pa0ent
-‐Wrong
Procedure
-‐Retained
Foreign
Object
-‐Post-‐op
death
of
an
ASA
Class
I
pa0ent
-‐Contaminated
drugs/
devices/biologics*
-‐Device
misuse/
malfunc0on*
-‐Air
embolism*
-‐Infant
discharged
to
wrong
person
-‐Pa0ent
elopement*
-‐Pa0ent
suicide/a)empted
suicide*
Care
Management
Environmental
Poten0al
Criminal
-‐Medica0on
Errors*
-‐Blood
Products*
-‐Maternal
death/disability
in
a
low-‐risk
pregnancy*
-‐Hypoglycemia*
-‐Hyperbilirubinemia*
-‐Stage
3
or
4
Pressure
Ulcer
-‐Spinal
manipula0on*
-‐Ar0ficial
insemina0on
error
-‐Pa0ent
fall*
-‐Electric
Shock*
-‐Oxygen/gas
lines*
-‐Burn*
-‐Fall*
-‐Physical
Restraints*
(*)
Denotes
pa0ent
death
or
serious
disability
required
-‐Impersona0on
of
a
healthcare
worker
-‐Abduc0on
of
a
pa0ent
-‐Sexual
assault
on
a
pa0ent
-‐Physical
assault
of
a
pa0ent
or
staff
member*
8. Clearly identifiable and measurable, and
therefore likely to include in a reporting
system.
Of a nature such that the risk of occurrence
is significantly influenced by the policies
and procedures of the health care facility.
Of concern to both health care providers
and the public.
According to the NQF, in order for a “Never
Event” to be reported, it must be:
9.
NQF is doing this by focusing on three main goals:
1. Reducing preventable hospital admissions and
readmissions.
2. Reducing the incidence of adverse healthcare-
associated conditions.
3. Reducing harm from inappropriate or
unnecessary care.
10. The Leapfrog Group is a a nonprofit quality-improvement organization
whose members work to improve regulations surrounding the quality of
healthcare.
According
to
the
Leapfrog
Group,
in
case
of
a
never
event,
hospitals
commit
to
follow
these
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.
11. • According to the IOM report “To Err is Human”, between
44,000-98,000 people die each year due to medical errors.
• Little progress to date - measures of patient safety showed an
average annual improvement of just 1 percent.
• Approximately two million healthcare-associated infections
occur annually in the United States, totaling an estimated $4.5
billion in hospital healthcare costs.
• According to patient safety researchers at Johns Hopkins
University who conducted a very careful analyses of patient
malpractice claims, estimate surgeons in the U.S:
-Leave a foreign object such as a sponge or a towel inside a patient’s body
after an operation 39 times a week.
-Perform the wrong procedure on a patient 20 times a week
-Operate on the wrong body site 20 times a week.
12. Steps
Towards
Minimizing
Never
Events
• Health
IT
• State
repor0ng
systems
• “No
Pay”
for
never
events
Health
IT
State
Repor/ng
Systems
“No-‐Pay’”
Events
13. Health
IT
• The
NQF
is
focused
on
making
healthcare
beFer
through
the
use
of
health
informa/on
technology.
• Electronic
Medical
Records
(EMR’s)
make
healthcare
safer,
coordinated,
and
allow
data
and
informa/on
to
be
shared
between
IT
systems.
• Clinical decision support
• Computerized disease registries
• Computerized provider order entry
• Electronic medical record systems
(EMRs, EHRs, and PHRs)
• Electronic prescribing
14. • 26
states
and
the
District
of
Columbia
have
state
repor0ng
systems
for
never
events.
• These
reports
help
healthcare
workers
iden0fy
and
learn
from
the
SRE’s.
• Although
most
states
follow
the
list
of
NQF’s
never
events,
the
differences
in
the
state’s
approach
to
repor0ng
events
hinder
the
NQF’s
efforts
in
finding
out
a
precise
number
of
how
many
never
events
actually
occur.
• Minnesota,
Connec0cut
and
New
Jersey
applied
mandatory
legisla0on
to
report
SREs
within
their
own
state-‐based
repor0ng
system.
15. • In
2008,
the
Centers
for
Medicare
&
Medicaid
Services
(CMS)
announced
they
will
no
longer
pay
hospitals
for
a
list
of
8
Hospital-‐Acquired
Condi0ons
(HACs).
• Many
private
insurance
companies
also
began
to
cease
payment
for
a
list
of
never
events.
• This
was
done
in
efforts
to
minimize
the
amount
of
preventable
errors
that
occur
and
mo0vate
healthcare
workers
to
avoid
making
these
preventable
mistakes.
16.
1. Pressure
ulcer
stages
III
and
IV
2.
Falls
and
trauma
3.
Surgical
site
infec0on
ajer
bariatric
surgery
for
obesity
4.
Vascular-‐catheter
associated
infec0on
5.
Catheter-‐associated
urinary
tract
infec0on
6. Administra0on
of
incompa0ble
blood
7. Air
embolism
8.
Foreign
object
uninten0onally
retained
ajer
surgery
17. Category
1
–
Health
Care-‐Acquired
Condi/ons
(For
Any
Inpa0ent
Hospitals
Semngs
in
Medicaid)
• Foreign
Object
Retained
ATer
Surgery
• Air
Embolism
• Blood
Incompa/bility
• Stage
III
and
IV
Pressure
Ulcers
• Falls
and
Trauma;
including
Fractures,
Disloca/ons,
Intracranial
Injuries
,
Crushing
Injuries,
Burns,
Electric
Shock
• Catheter-‐Associated
Urinary
Tract
Infec/on
(UTI)
• Vascular
Catheter-‐Associated
Infec/on
• Manifesta/ons
of
Poor
Glycemic
Control
• Surgical
Site
Infec/on
Following:
– Coronary
Artery
Bypass
GraT
– Bariatric
Surgery
– Orthopedic
Procedures;
including
Spine,
Neck,
Shoulder,
Elbow
• Deep
Vein
Thrombosis
(DVT)/Pulmonary
Embolism
(PE)
Following
Total
Knee
Replacement
or
Hip
Replacement
• Iatrogenic
Pneumothorax
with
Venous
Catheteriza/on
Category
2
–
Other
Provider
Preventable
Condi/ons
(For
Any
Health
Care
Semng)
• Wrong
Surgical
or
other
invasive
procedure
performed
on
a
pa0ent
• Surgical
or
other
invasive
procedure
performed
on
the
wrong
body
part
18. • Employee
Engagement
-‐
Emo0onal
a)achment
employees
feel
towards
workplace.
-‐
Connec0on
between
employee
engagement
and
healthcare
outcomes.
-‐
Studies
have
shown
that
hospitals
with
higher
nurse
engagement
levels
have
sta0s0cally
lower
mortality
and
complica0on
issues.
• Root
Cause
Analysis
-‐
A
method
of
problem
solving
used
for
iden0fying
the
“root
causes”
of
faults
or
problems.
-‐Very
important
for
management
to
perform
a
root
cause
analysis
ajer
a
never
event
in
order
to
inves0gate
the
issue
and
begin
the
process
of
solving
the
problem.
19. References
AHRQ
Pa0ent
Safety
Network
-‐
Never
Events.
(n.d.).
Retrieved
April
2,
2015,
from
h)p://psnet.ahrq.gov/primer.aspx?primerID=3
Health
IT
.
(n.d.).
Retrieved
March
30,
2015,
from
h)p://www.qualityforum.org/HealthIT
Hospitals:
Never
Have
a
Never
Event.
(n.d.).
Retrieved
April
2,
2015,
from
h)p://www.gallup.com/businessjournal/118255/hospitals-‐
event.aspx
Johns
Hopkins
Malprac0ce
Study:
Surgical
'Never
Events'
Occur
At
Least
4,000
Times
per
Year
-‐
12/19/2012.
(n.d.).
Retrieved
April
1,
2015,
from
h)p://www.hopkinsmedicine.org/news/media/releases/
johns_hopkins_malprac0ce_study_surgical_never_events_occur_at_least_4000_0mes_per_year
Lembitz,
A.,
&
Clarke,
T.
(n.d.).
Clarifying
"never
events
and
introducing
"always
events"
Retrieved
April
1,
2015,
from
h)p://
www.ncbi.nlm.nih.gov/pmc/ar0cles/PMC2814808/
(n.d.).
Retrieved
April
3,
2015,
from
h)p://www.ahrq.gov/professionals/quality-‐pa0ent-‐safety/pa0ent-‐safety-‐resources/resources/
advances-‐in-‐pa0ent-‐safety/vol4/Kizer2.pdf
(n.d.).
Retrieved
April
1,
2015,
from
h)ps://www.iom.edu/~/media/Files/Report
Files/1999/To-‐Err-‐is-‐Human/To
Err
is
Human
1999
report
brief.pd
(n.d.).
Retrieved
April
1,
2015,
from
h)p://www.leapfroggroup.org/media/file/Leapfrog-‐Never_Events_Fact_Sheet.pdf
When
Surgeons
Cut
the
Wrong
Body
Part.
(2007,
November
28).
Retrieved
April
1,
2015,
from
h)p://well.blogs.ny0mes.com