Preventing Never Events
The Centers for Medicare and Medicaid Services (CMS) publishes a list of health care-acquired conditions (HACs) that reasonably could have been prevented through the application of risk management strategies. What actions has your health care organization (or have health care organizations in general) implemented to manage or prevent these “never events” from happening within their health care facilities?
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Healthcare-acquired conditions (HACs), commonly referred to as “never events,” are serious, preventable incidents that should not occur in medical facilities if proper safety procedures are followed. To manage and prevent these events, healthcare organizations have implemented several risk management strategies that align with standards set by the Centers for Medicare and Medicaid Services (CMS). Some common actions include:
Preventing Never Events
1. Strict Adherence to Evidence-Based Protocols
Hospitals follow protocols such as the Surgical Care Improvement Project (SCIP) and central line-associated bloodstream infection (CLABSI) bundles. These protocols standardize care, reduce variability, and are proven to lower infection rates and surgical complications.
2. Staff Education and Training
Healthcare staff undergo ongoing training focused on infection control, proper hand hygiene, fall prevention, and safe surgical practices. Many organizations use simulation-based training to reinforce correct techniques and decision-making.
3. Use of Checklists and Safety Tools
Tools like surgical safety checklists, fall risk assessments, and pressure injury risk scales (e.g., Braden Scale) are widely used. These tools help clinical teams verify each step in a procedure and identify at-risk patients early.
4. Implementation of Electronic Health Records (EHRs)
EHRs include alerts and reminders for medication safety, allergy checks, and duplicate test warnings. These systems help prevent adverse drug events, one of the common categories of never events.
5. Infection Control Programs
Hospitals have established infection control departments that monitor compliance with CDC guidelines……….
6. Fall and Injury Prevention Programs
Facilities implement hourly rounding, non-slip flooring, adequate lighting, and patient education to reduce falls………
7. Root Cause Analysis (RCA) and Reporting Systems
When a never event occurs, organizations conduct a root cause analysis to identify what went wrong and how to prevent recurrence. They also use anonymous reporting systems to encourage staff to report near-misses or hazards without fear of punishment.
8. Leadership and Culture of Safety
Promoting a just culture and patient-centered care encourages transparency and proactive error prevention. Leaders support safety initiatives through policy-making and funding for quality improvement programs.
Example from Practice:
For instance, preoperative “time-outs” before surgery ensure that the right patient is getting the right procedure. In intensive care units, adherence to ventilator bundles has drastically reduced ventilator-associated pneumonia rates.
