Abstract
The incidence of ‘never events’ is challenging to quantify due to the remaining confusion that lies between the NQF and the CMS definitions. The former defines patient - centered events that must never occur, most being at least potentially preventable. The later is more financially driven and penalizes hospitals in which these events, in most part non preventable, occur. It is crucial that the general public understands the differences so as to avoid future law suits for non preventable never events occurrences. Physicians must drive the universal implementation of a culture of patient safety. This process should focus on positive behaviors with an emphasis on ‘always events’. These events should be standardized and validated.
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References
Hadjipavlou AG, Marshall RW. Wrong site surgery: the maze of potential errors. Bone Joint J. 2013;95-B(4):434–5. doi:10.1302/0301-620X.95B4.31235.
Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C, Institute of Medicine. To err is human: building a safer health system. Washington, DC: The National Academies Press; 2000. ISBN-13: 978-0-309-26174-6 (800-624-6242).
Lembitz A, Clarke T. Clarifying “never events” and introducing “always events”. Patient Saf Surg. 2009;3:26.
Brilli RJ, McClead RE Jr, Crandall WV, Stoverock L, Berry JC, Wheeler TA, Davis JT. A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality. J Pediatr. 2013;163(6):1638–45.
Schoenfeld AJ, Ochoa LM, Bader JO, Belmont PJ. Risk factors for immediate post-operative complications and mortality following spine surgery: a study of 3475 patients from the national surgical quality improvement program. J Bone Joint Surg. 2011;2011:1577. doi:10.2106/JBJS.J.01048.
Basey AJ, Krska J, Kennedy TD, Mackridge AJ. Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Qual Saf. 2014;23(1):17–25. doi:10.1136/bmjqs-2013-001978.
Bates DW, Lucian LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280(15):1311–16. doi:10.1001/jama.280.15.1311.
Peikari HR, Zakaria MS, Yasin NM, Shah MH, Elhissi A. Role of computerized physician order entry usability in the reduction of prescribing errors. Healthc Inform Res. 2013;19(2):93–101. doi:10.4258/hir.2013.19.2.93.
Borycki E. Trends in health information technology safety: from technology-induced errors to current approaches for ensuring technology safety. Healthc Inform Res. 2013;19(2):69–78. doi:10.4258/hir.2013.19.2.69.
Mogensen CB, Olsen I, Thisted AR. Pharmacist advice is accepted more for medical than surgical patient in an emergency department. Dan Med J. 2013;60(8):A4682.
Cobb TK. Wrong site surgery – where are we and what is the next step? Hand (NY). 2012;7:229–32. doi:10.1007/s11552-012-9405-5.
Ring DC, Herndon JH, Meyer GS. Case records of The Massachusetts General Hospital: Case 34-2010: a 65-year-old woman with an incorrect operation of the left hand. N Engl J Med. 2010;363(20):1950–7.
Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf. 2014;23(4):299–318.
Cima RR, et al. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80–7. doi:10.1016/j.jamcollsurg.2007.12.047.
Lincourt AE, Harrell A, Cristiano J, Sechrist C, Kercher K, Heniford BT. Retained foreign bodies after surgery. J Surg Res. 2007;138(2):170–4.
Greenberg CC, Regenbogen SE, Lipsitz SR, Diaz-Flores R, Gawande AA. The frequency and significance of discrepancies in the surgical count. Ann Surg. 2008;248(2):337–41. doi:10.1097/SLA.0b013e318181c9a3.
Cima RR, Kollengode A, Storsveen AS, Weisbrod CA, Deschamps C, Koch MB, Moore D, Pool SR. A multidisciplinary team approach to retained foreign objects. Jt Comm J Qual Patient Saf. 2009;35(3):123–32.
Cross MB, Boettner F. Pathophysiology of venous thromboembolic disease. Semin Arthro. 2009;20:210–16. doi:10.1053/j.sart.2009.10.002.
Gilmore R, Doyle M, Holden F, White B, O’Donnell J. Activated protein C resistance, factor V Leiden and assessment of thrombotic risk. Ir Med J. 2008;101(8):256–7.
Morris CD, Creevy WS, Einhorn TA. Chapter 12: Pulmonary distress and thromboembolic conditions affecting orthopaedic practice. In: Buckwalter JA, Einhorn TA, Simon SR, editors. Orthopaedic basic science: biology and the biomechanics of the musculoskeletal system. 2nd ed. American Academy of Orthopaedic Surgeons, Chicago, IL. 2000.
Itatsu K, Sugawara G, Kaneoka Y, Kato T, Takeuchi E, Kanai M, Hasegawa H, Arai T, Yokoyama Y, Nagino M. Risk factors for incisional surgical site infections in elective surgery for colorectal cancer: focus on intraoperative meticulous wound management. Surg Today. 2013. Epub ahead of print.
Pruzansky JS, Bronson MJ, Grelsamer RP, Strauss E, Moucha CS. Prevalence of modifiable surgical site infection risk factors in hip and knee joint arthroplasty patients at an urban academic hospital. J Arthroplasty. 2014;29(2):272–6.
Fakih MG, Heavens M, Ratcliffe CJ, Hendrich A. First step to reducing infection risk as a system: evaluation of infection prevention processes for 71 hospitals. Am J Infect Control. 2013;41(11):950–4.
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Cross, M.B., Mauffrey, C. (2014). Incidence of ‘Never Events’ and Common Complications. In: Stahel, P., Mauffrey, C. (eds) Patient Safety in Surgery. Springer, London. https://doi.org/10.1007/978-1-4471-4369-7_2
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