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Never Events
Serious Reportable Events (aka “Never Events”)
Leslie G. Selbovitz, MD
The efforts to expand the public awareness of Serious Adverse Events, formerly termed “Never Events” by the National Quality Forum (NQF), have grown in many directions. The new NQF list has identified 28 event types that qualify for the "Never" list. The NQF qualifications for classification as a 'Never Event' purportedly are: unambiguous, usually preventable, create serious injury (which may be temporary) and have other characteristics of flawed systems. The entire list is available at www.qualityforum.org.
While such event characteristics had previously been mandated reports to the Massachusetts Department of Public Heath and/or the Massachusetts Board of Registration in Medicine, several of these adverse events that occur as complications or deaths after admission will also affect payment to hospitals negatively under the (at times erroneous) assumption that nearly all of these events are preventable. This approach is being adopted by the Centers for Medicare and Medicaid Services (CMS) with private payers following.
It is vital to document whether all medical conditions are POA (Present on Admission). If they are, the hospital is not penalized for their presence. If you cannot determine POA, please so indicate your uncertainty.
Current examples of serious “preventable” events include occurrences such as unintentionally retained foreign bodies after surgery; air embolism; blood incompatibility; development of Stage 3 and 4 pressure ulcers; falls with trauma; nosocomial infections including vascular-associated catheter infections and catheter-associated UTIs. These indicators are currently active. For the next fiscal year (FY’09) a significantly expanded list of Healthcare Associated Conditions (HAC) is being proposed which will include surgical site infections for a number of elective procedures; glycemic control; iatrogenic pneumothorax; delirium; ventilator associated pneumonia; DVT/PE; Staphylococcus aureus bacteremia and sepsis; C-diff infections and even Legionnaires Disease as a result of contaminants in the hospital water supply. For the latest review of the FY’09 proposals, there is an opportunity to comment by 06-13-08 through http://www.regulations.gov.
Please be aware that these reports are kept as confidential and deidentified as possible. The other issue that continues to stir debate is what is meant by “preventable” Serious Reportable Events; are they possibly, probably or definitely preventable when one looks at the system as a whole. In addition, Newton-Wellesley Hospital will soon be reporting to the State key hospital acquired infections in ever expanding domains.
This entire subject matter merits our watching.
View PCP Open Panels List (pdf)
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