This article contains two interesting tables related to “never events,” a term introduced in 2001 by Dr. Kenneth Kizer, then the CEO of the National Quality Forum, to describe the most serious types of health care errors. The first table itemizes the lists of never events developed by four organizations in a side-by-side comparison. For example, retention of a foreign object in the patient after surgery is listed by all four organizations, which include:
- National Quality Forum / Leapfrog Group
- Centers for Medicare & Medicaid Services (CMS)
- The Joint Commission
- The National Health Service (United Kingdom)
The second table compares each of the states and the District of Columbia on whether hospitals are required to report adverse events, whether the state reports individual hospital data, and whether the state reports aggregate data.
What I like about this article: 1.) Useful side-by-side comparison of existing lists of never events. (One of the recommendations of the article is that work should be done on creating a single definition of never events.) 2.) Authoritative source – the authors are with the Armstrong Institute for Patient Safety and Quality at Johns Hopkins. Dr. Pronovost, especially, is a prolific author on topics related to patient safety.
Source: Austin, J.M., and Pronovost, P. (2015, June). “Never events” and the quest to reduce preventable harm. The Joint Commission Journal on Quality and Patient Safety, 41(6), 279-288. Retrieved from http://www.jcrinc.com/reducing-never-events-and-preventable-harm-in-health-care/ Posted by AHA Resource Center (312) 422-2050, email@example.com