The Never Events in Health Care

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TheNever Events in Health Care


TheNever Events in Health Care

Someof the mistakes done in hospitals are quite shocking and abominablethat they are termed as ‘Never Events.’ These happenings are alsoknown as serious reportable events. They are unusual and serioushealthcare errors which are avoidable and should never occur to anypatient (Watson, 2010). These errors comprise of surgeries performedon wrong parts of the body or the wrong patients, objects left insidethe body of a patient after completion of a surgery, deaths fromwrong medications, and severe injury or death from a fall in amedical center among others. These Never Events are identified andapproved by the National Quality Forum (NQF) in order to ensureproper patient care in all the medical centers (Watson, 2010). NQF isa public corporation that aims at setting general priorities andobjectives in relation to the patients’ safety.

Regardlessof their name, the Never Events kept occurring in most of thehospitals all over the world. Therefore, this led to the developmentof the Leapfrog Group in 2000 to merge the purchasing power whileestablishing resources that enhance quality health care. Leapfrogensures that all medical centers manage the Never Events throughpolicies which include informing and apologizing to patients andfamilies and reporting certain errors to the agencies upon therealization of their occurrence (Watson, 2010). Moreover, thehospitals should ensure that they evaluate the root-cause of theevents ignoring the operational costs to ensure patient care. Throughheeding to these policies, hospitals portray their accountability totheir clients and dedication towards constant improvement.

Inaddition, the NQF enhanced the Never Events towards the country’sattention in 2006. It published the first report indicating anddescribing the errors. However, The Centers for Medicare &ampMedicaid Services (CMS) later released a statement describing how theNever Events cause severe injuries or death to patients, leading toincreased costs to the CMS program to treat the effects of themistakes (Watson, 2010). This has led to a decrease in thereimbursements by the CMS program to hospitals when the Never Eventsoccur. In reaction to the national attention, Leapfrog added newpolicies to the medical survey to ensure that all hospitals implementthe best practices to ensure patient care. Moreover, Leapfrog programgave several steps that healthcare centers should follow in case aNever Event occurs. The hospital should first make an apology to theclient and family members in order to preserve the client’s dignityand rebuild trust between the patient and the hospital (Watson,2010). Thereafter, there should be a report on the event made to anoutside agent within ten days after the realization of the error. Theroot cause of the error should then be evaluated to prevent futurehappenings of the same mistakes. Besides, the hospitals should reviewthe cases to define the costs that are related to the Never Event.Lastly, the hospital should ensure transparency by making copies ofthe policies to give to the patients, their family members, and thepayers.

Withthe Never Events policies, the adoption of hospitals varies from onestate to another. Pennsylvania and Minnesota are some of the statesrecognized for their commitment to giving reports on the NeverEvents. As time elapsed, more hospitals got involved in the NeverEvents program after the realization of its significance (Watson,2010). Although the Leapfrog survey indicated a rise in the number ofhospitals involved, there were few policy reports made upon NeverEvents. The survey also shows that there are some hospitals thatbarely report any data on the never events. This, therefore, offers alimitation in the national data on the never events policies as wellas the crucial information concerning the hospital’s quality careand security.

Thenever events policy is necessary as it influences the clients to makeinformed decisions when looking for medical attention and care.Additionally, these policies give a benchmark of the hospitals’progress in administering the appropriate standards of care (Bell,2010). The Leapfrog Groups calls upon all hospitals including thepediatrics hospital and the overall acute-care hospitals. In theUnited States, all hospitals are called upon to volunteer in makingreports on various topics including maternity care, high-riskoperations, certain medical infections, medication and nursingsecurities, and the never events through the hospital surveyprograms.

Finally,it is important that all hospitals join the Leapfrog Group in theimplementation of the Never Events policy. With this group surveyprogram, the medical centers will be able to participate in theNational Quality Forum to promote the Never Events policies.Furthermore, the CMS will benefit from this program since it will beable to manage the operations of all the hospitals. The establishmentof the never events list is only a beginning step. The healthcareexecutives and staff members including doctors and nurses amongothers should ensure that they animate this list and adhere to itthrough the creation and adoption of procedures that prevent thenever events from happening in the nation’s hospitals. The main aimshould be to facilitate proper care to all patients seeking medicalattention in the hospitals. Therefore, the never events policies bythe Leapfrog Group will enable the achievement of this goal andgrowth of the medical industry.


Bell,L. (2010). Patient safety and medical error recovery. AmericanJournal of Critical Care,19(6),510-510.

Watson,D. (2010). Never events in health care. AORNJournal,91(3),378-382.