Wrong-site surgery, hospital-acquired pressure ulcers, labor and delivery issues, foreign object intrusion, and incorrect dosage and medication are just a few examples of serious reportable events (SREs). Also called “never events,” these SREs should never occur in the hospital setting and are largely preventable if proper training protocols are instituted.
In 2002, the official list of publicly reported never events was published by the National Quality Forum (NQF), a nonprofit organization of healthcare providers, businesses, and policymakers. The aim was to develop and implement a national quality measurement and reporting system. The organization notes that never events are entirely preventable medical errors. However, should they occur, the repercussions are costly.
Never Events: Serious, Reportable Adverse Medical Errors
The 1999 IOM report, To Err is Human: Building a Safer Health System, estimated that 98,000 patients die annually in hospitals as a result of adverse medical events or sentinel events. Not surprisingly, this report attracted a tremendous amount of public attention that pointed fingers and demanded answers.
A second report, Crossing the Quality Chasm, described how rapid advances in technology, increased patient complexity, and the disconnect in communication across different departments were stifling patient care and costing healthcare organizations millions of dollars.
“The complexity of healthcare … is characterized by more to know, more to do, more to manage, more to watch, and more people involved than ever before.”
According to Patient Safety and Quality: An Evidence-Based Handbook for Nurses, the original intent of the IOM committee was to emphasize that never events are not a property of a health care professional’s competence, good intentions, or hard work. Instead, the safety of care—defined as “freedom from accidental injury”—is a system of care in which specific attention is given to ensuring well-designed care processes and recovery from errors.
Never Events Prevention in the Healthcare Industry
Nurses play a crucial role in the prevention of never events because they are often the final line of defense between error and patient. The prevention of never events often boils down to sufficient training and education emphasizing patient safety and proper documentation. In cases where never events occur, it is critical all events reported are highly detailed and sufficiently understood by staff to reduce the likelihood of the incident occurring again.
1. Establish and Emphasize Safe Practices and a Safety Protocol
Management of continued safety awareness is crucial to establishing staff and patient safety. Proper tools allow hospitals and surgery centers to create customized safety plans and manage all employee safety data sheets. Staff can easily log in to their accounts and search their “binders” for the necessary safety protocol for proper precautions, such as first aid procedures, personal protective equipment, and storing and handling of hazardous materials.
2. Identify and Prevent Risk
The mechanisms required for an organization to reduce overall risk, never events, and provide superior patient protection are often lost due to an endless barrage of information and data that is neither efficient nor timely. Comprehensive compliance and training software enables leadership to dedicate the data and resources needed to keep providers and staff informed and involved in real-time risk mitigation.
3. Educate Staff With Quality Continued Education
Training relevant to incidents that are likely to occur within a healthcare facility is an important consideration when trying to improve the knowledge and competency of healthcare workers. Compliance management software enables administrative staff to assign and track relevant training for key personnel to ensure all staff members meet training requirements.
4. Properly Document All Records, History, and Adverse Events
Enforcing proper documentation is key to reducing the likelihood of never events and establishes accountability. Many organizations lack historical data around all types of incident reporting, risk mitigation measures, training, and other compliance metrics. This data can irradiate potentially risky decisions and identify gaps in the process to assimilate information and data into actionable steps that prevent or eliminate never events.
MedTrainer®: Ensuring Compliance Throughout Your Healthcare Facility
Healthcare compliance tools that incorporate training, incident reporting, best-practice policies, national standards, and competency guidelines can assist healthcare professionals in identifying risks that are associated with the potential for never events.
Creating a system of requirements that are instantly available for users and supported by leadership, encouraging reporting “near-misses,” can help focus the program on identifying and mitigating risk at the point of contact. It also maintains compliance with the requirements set forth by the Centers of Medicare and Medicaid Services, other federal and state agencies, and third-party entities.
MedTrainer®’s exclusive software tools include equipment lifecycle management tracking and a broad range of other comprehensive services to streamline your administrative procedures.
Contact us today to learn our all-in-one software solutions for healthcare providers.