Wrong-site surgery, hospital-acquired pressure ulcers, 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. In 2002, the official list of never events was published by the National Quality Forum (NQF), a nonprofit organization of healthcare providers, businesses and policy makers whose aim is 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. Not surprisingly, this report attracted a tremendous amount of public attention that pointed fingers and demanded answers. Not long thereafter, a second report, Crossing the Quality Chasm, described how rapid advances in technology, increased patient complexity, and the disconnect in communication across different departments due to incomplete patient information 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. Rather, the safety of care—defined as “freedom from accidental injury”—is a property of a system of care in which specific attention is given to ensuring that well-designed processes of care prevent, recognize and quickly recover from errors so that patients are not harmed.
The Prevention of Never Events
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 with an emphasis on patient safety and proper documentation.
- 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 login 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.
- Identify and prevent risk
The mechanisms required for an organization to reduce overall risk and never events are often lost due an endless barrage of information and data that are 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.
- Educate staff with quality continued education
Training that is relevant to incidents that are likely to occur within an organization 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 trainings for key personnel to ensure all staff members meet training requirements.
- 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.
Compliance software that incorporates 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 comprehensive system of required procedures that are instantly available for users and supported by leadership’s encouragement and ease of reporting “near-misses,” can help to focus the compliance program on the identification and mitigation of risk at the point of contact.