Jeffrey Wade
Never Events refer to particularly shocking medical errors that should never occur and are considered serious, adverse events that are unambiguous, serious, and usually preventable. The term was first introduced in 2001 by Ken Kizer, former CEO of the National Quality Forum (NQF), and has since expanded to include 29 serious reportable events grouped into 7 categories. These events are considered devastating to patients and indicate fundamental safety problems within a healthcare organization. In response, the Centers for Medicare and Medicaid Services (CMS) have adopted a non-reimbursement policy for certain never events to motivate hospitals to improve patient safety and reduce costs associated with preventable errors. This has led to increased accountability and public reporting of never events, with some states mandating root cause analysis and corrective actions. The goal is to eliminate these events and improve the quality of care, while also addressing the challenges of varying payment systems and profitability for hospitals.
| Characteristics | Values |
|---|---|
| Definition | Particularly shocking medical errors that should never occur |
| Initiated By | Ken Kizer, MD, former CEO of the National Quality Forum (NQF) |
| Year | 2001 |
| Examples | Wrong-site surgery, mismatched blood transfusion, foreign body left in a patient after surgery, major medication error, severe pressure ulcer acquired in the hospital, preventable post-operative deaths |
| Occurrence | A 2006 study estimated that a typical hospital might experience a case of wrong-site surgery once every 5 to 10 years. A 2013 study estimated that more than 4000 surgical never events occur yearly in the United States. |
| Preventability | Preventable |
| Cost | A study concluded that "never events" add significantly to Medicare hospital payments, ranging from an average of an additional $700 per case to treat decubitus ulcers to $9,000 per case to treat postoperative sepsis |
| Accountability | Hospitals are accountable for correcting systematic problems that contributed to the event. Some states mandate performance of a root cause analysis and reporting of its results. |
| Reporting | Hospitals are required to track, analyze, and publicly report some or all of the NQF "never events." |
| Non-Reimbursement | The Centers for Medicare and Medicaid Services (CMS) announced in August 2007 that Medicare would no longer pay for additional costs associated with many preventable errors, including those considered Never Events |
| Patient Safety | The concept of "always events" represents a positive affirming behavior that can motivate us to improve patient safety and promote better outcomes |
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What You'll Learn
- Never Events refer to serious, preventable, and costly medical errors that should never happen
- The Centers for Medicare and Medicaid Services (CMS) has a non-reimbursement policy for certain Never Events
- The National Quality Forum (NQF) has identified 27 Never Events, including wrong-site surgery
- Never Events result in serious harm or death and increased costs for Medicare
- Some states have enacted legislation requiring hospitals to report Never Events
Never Events refer to serious, preventable, and costly medical errors that should never happen
"Never Events" refer to serious, preventable, and costly medical errors that should never happen. The term was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), to refer to particularly shocking medical errors such as wrong-site surgery. These events are unambiguous, serious, and usually preventable. They are also devastating to patients and indicate a fundamental safety problem within a healthcare organization.
Since the initial list was developed in 2002, it has been revised multiple times and now consists of 29 "serious reportable events" grouped into 7 categories. Examples of "Never Events" include surgery on the wrong body part, foreign bodies left in a patient after surgery, mismatched blood transfusions, major medication errors, and severe pressure ulcers acquired in hospital.
The Centers for Medicare and Medicaid Services (CMS) has adopted a non-reimbursement policy for certain "Never Events" to motivate hospitals to improve patient safety by implementing standardized protocols. This policy limits hospitals' ability to bill Medicare for adverse events and complications, and many states and private insurers have followed suit. Additionally, some states have enacted legislation requiring the reporting of incidents on the NQF list, with Minnesota being the first to pass such a statute in 2003.
The NQF list of "Never Events" has raised concerns about public confusion between the two lists based on distinct definitions by the NQF and CMS. While most of the events on the NQF list likely carry liability, many of the non-reimbursable CMS "Never Events" are not completely preventable, even with the best practices of evidence-based treatment. This has led to concerns that patients experiencing these events will be inaccurately told that they were due to negligence or medical errors.
In conclusion, "Never Events" are serious, preventable, and costly medical errors that should never occur. They have led to significant efforts to improve patient safety and reduce their occurrence, including through the adoption of non-reimbursement policies and mandatory reporting requirements. However, there are still challenges in ensuring accurate reporting and addressing public confusion between the NQF and CMS definitions.
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The Centers for Medicare and Medicaid Services (CMS) has a non-reimbursement policy for certain Never Events
The term "Never Event" was first introduced in 2001 by Ken Kizer, former CEO of the National Quality Forum (NQF), to refer to particularly shocking medical errors that should never occur, such as wrong-site surgery. These events are unambiguous, serious, and usually preventable.
CMS's selection criteria for hospital-acquired conditions (HACs) overlap with eight of the events on the NQF's list, including the "'wrong surgery' category. In 2008, CMS announced new payment and coverage policies under the Inpatient Prospective Payment System (IPPS) FY 2009 final rule, expanding the list of HACs with Medicare payment implications. CMS has also initiated three Medicare National Coverage Determinations (NCD) proceedings for "wrong surgery," and advised State Medicaid Agencies of their authority to deny payment for selected HACs.
While the CMS non-reimbursement policy aims to improve patient safety, it has faced concerns about potential unintended consequences. Critics argue that it may disincentivize the reporting of adverse events and unfairly penalize hospitals for so-called "preventable" events that may be unavoidable in practice. Additionally, there is confusion between the NQF and CMS definitions of "never events", with most of the events on the NQF list carrying liability, while many of the CMS "never events" are not completely preventable even with evidence-based treatment.
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The National Quality Forum (NQF) has identified 27 Never Events, including wrong-site surgery
The term "Never Event" was introduced by the former CEO of the National Quality Forum (NQF), Ken Kizer, in 2001. It refers to shocking medical errors that are unambiguous, serious, and usually preventable. These events should never occur and have devastating consequences for patients when they do.
The NQF identified 27 Never Events, including wrong-site surgery, which falls under the category of adverse events that are clearly identifiable and measurable, resulting in death or significant disability. Wrong-site surgery is a specific type of Never Event that involves performing surgery on the wrong body site or side, or even the wrong patient, which can have severe and lasting repercussions.
To prevent wrong-site surgery, higher-level policies and programs have been implemented by several organizations, including the American Academy of Orthopaedic Surgery and the North American Spine Society Associations. These policies aim to reduce the occurrence of such events and improve patient safety. However, no scientific evidence is available to guide hospitals in evaluating the effectiveness of their policies or staff knowledge in preventing these incidents.
In addition to wrong-site surgery, other examples of Never Events include retained foreign objects after surgery, air embolism, blood incompatibility, stage III & IV pressure ulcers, falls, electric shock, and burns. The Centers for Medicare and Medicaid Services (CMS) have also adopted the non-reimbursement policy for certain Never Events, limiting hospitals' ability to bill Medicare for adverse events and complications. This policy aims to motivate hospitals to improve patient safety by implementing standardized protocols.
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Never Events result in serious harm or death and increased costs for Medicare
"Never Events" refer to particularly shocking medical errors that should never occur and result in serious harm, death, and increased costs for Medicare. The term was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), to describe adverse events that are unambiguous, serious, and usually preventable. These events indicate a fundamental safety problem within a healthcare organization and have led to increased pressure on healthcare providers to eliminate them.
Never Events include instances such as wrong-site surgery, patient death or serious injury associated with contaminated drugs or devices, and mismatched blood transfusions. These events are considered sentinel events, defined as patient safety events that result in death, severe harm, or permanent harm, regardless of the patient's underlying condition. The occurrence of Never Events results in increased costs for Medicare, as the program is responsible for treating the consequences of these errors.
In August 2007, the Centers for Medicare and Medicaid Services (CMS) announced that Medicare would no longer pay for the additional costs associated with many preventable errors, including Never Events. This decision was made to motivate hospitals to improve patient safety and reduce costs. Since then, many states and private insurers have followed suit, refusing to reimburse for costs associated with Never Events.
The exact number of Never Events is unknown, but they have resulted in many deaths and increased healthcare costs. A study reviewing 18 types of medical events concluded that medical errors may account for 2.4 million extra hospital days, $9.3 billion in excess charges, and 32,600 deaths. Another study found that 25% of Medicare patients experienced patient harm during their hospital stays in October 2018, with nearly a quarter of these cases requiring additional treatment and resulting in higher Medicare costs.
The efforts to reduce Never Events include standardizing protocols, improving patient safety, and implementing quality standards. Public reporting of Never Events also aims to increase accountability and improve the quality of care. Healthcare facilities are responsible for correcting systematic problems and addressing the root causes of these events.
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Some states have enacted legislation requiring hospitals to report Never Events
The term "Never Event" was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), to refer to particularly shocking medical errors that should never occur. These include adverse events that are unambiguous, serious, and usually preventable. Since the initial list of Never Events was developed in 2002, it has been revised multiple times and now consists of 29 "serious reportable events" grouped into 7 categories.
In 2007, the Centers for Medicare and Medicaid Services (CMS) announced that Medicare would no longer pay for the additional costs associated with many preventable errors, including those considered Never Events. Following this, many states and private insurers adopted similar policies, and some states enacted legislation requiring hospitals to report Never Events. For instance, in 2003, Minnesota became the first state to pass a statute mandating the reporting of the NQF's 27 Never Events to the Minnesota Hospital Association's Patient Safety Registry. During the first year of mandatory reporting, 30 hospitals reported 99 events resulting in 20 deaths and four serious disabilities. In the second year, 47 hospitals reported 106 events resulting in 12 deaths and nine serious injuries.
In 2004, New Jersey enacted a law requiring hospitals to report serious, preventable adverse events to the state and patients' families, and Connecticut adopted a mix of 36 NQF and state-specific reportable events for hospitals and outpatient facilities. These state-based reporting systems help improve patient safety and promote accountability by identifying and addressing systematic problems that contribute to Never Events.
The CMS has also launched various demonstrations aimed at improving the quality of care, such as the Physician Group Practice Demonstration and the Premier Hospital Quality Incentive Demonstration. These initiatives tie payment to the quality of care provided, encouraging hospitals to implement standardized protocols to enhance patient safety and reduce wasted spending.
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Frequently asked questions
A "never event" is a medical error that should never occur. These include wrong-site surgery, patient suicide, and catheter-related urinary tract infections, among others.
The "never-event" initiative refers to Medicare's policy of not paying for the treatment of preventable, hospital-acquired conditions that were not present when the patient was admitted. This policy aims to reduce the occurrence of "never events" and improve patient safety.
Medicare and certain private health insurance companies use a diagnosis-related group (DRG) payment system, where hospitals are paid a fixed amount based on a patient's diagnosis and treatment, regardless of the actual cost of treatment. In the context of "never events", some insurance companies have adopted a dual strategy by refusing to pay for services resulting from these events and publicly reporting them.
