EDITORIAL OPINION

Never Events: A Patient Safety ImperativeJan Odom-Forren, MS, RN, CPAN, FAAN

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DO YOU REMEMBER hearing your grand-

mother say, ‘‘Well, I never.!’’ The ending ofthis exclamation was left open for the hearerto insert the appropriate phrase. Well, Inever—saw such a strange sight or saw an out-fit like you have on or heard kids talk back totheir parents like that. Fill in the blank. Nowwe have the term ‘‘never events’’ which seemsto me to be a misnomer. An event that shouldnever occur should not be an event at all! It re-minds me of a ‘‘near miss’’ which I think wouldbe more accurately named a ‘‘near hit’’ thana ‘‘near miss.’’ You don’t almost ‘‘miss’’ anotherplane, you almost ‘‘hit’’ them—you did ‘‘miss’’them! But that’s just me. What are ‘‘neverevents?’’ ‘‘Never events’’ are medical errorsthat are identifiable and preventable thatresult in serious consequences.

The National Quality Forum (NQF) is a non-

profit organization committed to patient qual-

ity measurement and reporting with a mis-

sion to improve quality of care by setting

national priorities and goals for performance

improvement. NQF is made up of groups rep-

resenting consumers, purchasers, health care

professionals, employers, provider organiza-

tions, labor unions, accrediting bodies, and

organizations involved in health care research

or quality improvement.1 NQF has identified

28 ‘‘serious reportable events’’ that should

never occur in a hospital and are now called

‘‘never events.’’2 They include surgical events

such as a retained foreign object, surgery per-

formed on the wrong body part or wrong pa-

tient, or wrong procedure performed. Other

events include patient death from medication

error, infant discharged to the wrong person,

and stage 3 or 4 pressure ulcers acquired

after care in a health care facility (Table 1).

Journal of PeriAnesthesia Nursing, Vol 23, No 4 (August), 2008: pp 223-225

No Pay for Never Events

A big shift in thinking about reimbursement isoccurring. There is an emerging belief thathospitals should not be reimbursed for eventsthat should never occur—that it is a patientsafety and ethical imperative. Blue CrossBlue Shield announced last year that theywill work toward plans that will end pay fornever events. Hospitals are also stepping for-ward. Minnesota hospitals and insurers, lastyear, agreed that patients and health planswould not be billed for care associated withthe list of 28 never events endorsed by NQF.Massachusetts hospitals also announced thatthey will not bill for nine NQF never events.Nearly 1,300 hospitals nationally have pledgedto waive costs directly associated with neverevents.3 The Michigan Health and HospitalAssociation has also declared their intent tostop billing patients for never events as partof a patient safety initiative. The member hos-pitals will not bill for eight of the NQF en-dorsed events and three hospital acquiredinfections.4 Why the shift?

The Centers for Medicare and Medicaid (CMS)issued a rule in August 2007 to take effect inOctober 2008 that will deny payment for eighthospital-acquired conditions. Five of the eight

The ideas or opinions expressed in this editorial are those

solely of the author and do not necessarily reflect the opinions

of ASPAN, the Journal, or the Publisher.

Jan Odom-Forren, MS, RN, CPAN, FAAN, is a Perianesthesia

Nursing Consultant in Louisville, KY, and a PhD candidate

at the University of Kentucky, Lexington, KY.

Address correspondence to Jan Odom-Forren, MS, RN,

CPAN, FAAN, 800 Edenwood Circle, Louisville, KY 40243;

e-mail address: jodom29373@aol.com.

� 2008 by American Society of PeriAnesthesia Nurses.

1089-9472/08/2304-0001$34.00/0

doi:10.1016/j.jopan.2008.07.002

224 JAN ODOM-FORREN

Table 1. National Quality Forum Reportable Adverse Events (Never Events)2,5,7

Surgical Events

� Surgery on wrong body part

� Surgery on wrong patient

� Wrong surgery on a patient

� Foreign body left in patient after surgery or procedure

� Death intraoperatively or immediately postoperative in normal health patient (ASA Class 1)

� Artificial insemination with wrong sperm or wrong egg

Product or Device Events

� Death/disability associated with use of contaminated drugs, devices, or biologics

� Death/disability associated with use of device other than that intended

� Death/disability associated with intravascular air embolism

Patient Protection Events

� Infant discharged to wrong person

� Death/disability due to patient elopement (disappearance)

� Patient suicide or attempted suicide resulting in disability

Care Management Events

� Stage 3 or 4 pressure ulcers acquired after admission

� Death/disability associated with:

B Medication error

B Incompatible blood or blood products

B Hypoglycemia

B Hyperbilirubinemia in neonates

B Maternal death in low risk delivery

B Spinal manipulative therapy

Environment Events

� Incident due to wrong gas in oxygen or other gas line or other toxic contaminates in line

� Death/disability associated with:

B Electric shock

B A burn from any source incurred within a facility

B Use of restraints or bedrails within a facility

Criminal Events

� Impersonating a health care provider (physician, nurse, or other licensed health care provider)

� Abduction of a patient

� Sexual assault of a patient within or on facility grounds

� Death/disability of patient or staff member resulting from physical assault within or on facility grounds

events are from the NQF list of never events.Many other private payers will follow thelead of CMS after implementation.3 This yearCMS has proposed an additional nine cate-gories of health care acquired conditions thatwould fit the payment provisions in the inpa-tient prospective payment system, includingseveral identified by NQF.5

The Leapfrog Group has also gotten into theaction with adoption of a Leapfrog Never

Events policy. The Leapfrog Group wasfounded in 2000 by the Business Roundtableand is supported by the Robert Wood JohnsonFoundation, The Commonwealth Fund, TheAgency for Healthcare Research and Quality,its members, and other sources. This NeverEvents policy is a list of actions that hospitalsagree to take when a never event occurs. Leap-frog uses the NQF’s definition and list of neverevents. Hospitals who adhere to Leapfrog’sNever Events policy agree to:

� Apologize to the patient and/or family af-ter the event and offer an explanation ofknown circumstances.� Report the event within ten days to one

of the following agencies: the Joint Com-mission, a Patient Safety Organization,a state reporting program for medicalerrors.� Perform a root cause analysis to identify

the causal factors and to improve the sys-tems and processes.� Waive all costs directly related to the

never event to protect the patient frominappropriate payment.6

What Does This Mean?

As perianesthesia nurses, we may wonder howthis all impacts us. For one thing, there may bea fiscal impact. No reimbursement for neverevents will impact the bottom line—especiallyof hospitals not using evidence-based guide-lines to decrease infections and minimizemedical error. We may be asked to sit on com-mittees to determine best practice or becomea part of consumer-driven initiatives to im-prove performance. At the personal level, itmay be as simple as handwashing or thoroughand accurate handoffs. At the very least, wecan become informed about the issues. InJuly, we heard of a ‘‘never event’’ when it waswidely reported that 14 premature babies ina Texas hospital had received a massive over-dose of heparin. Dennis Quaid’s newborntwins received an overdose of the same medi-cation just last year in California. In this issueof JoPAN, several columnists discuss timelyissues that surround ‘‘never events.’’ In thepharmacology column, Julie Golembiewski

EDITORIAL OPINION

discusses the drug heparin with a focus onsafety, and Debbie Sandlin, in the resource col-umn, discusses prevention of pediatric medi-cation errors. On another note, developmentof a pressure ulcer during a hospital stay isa ‘‘never event’’ discussed by columnist EllenSullivan. In Clinical Clips, she details how peri-anesthesia nurses in her facility facilitate pre-vention of those ulcers. In our nursingcareers, we not only are providers of care,but at some point in life become consumersof the very product that we deliver—an impor-tant point to remember as we deliver safe, effi-cient, and quality care.

References

1. National Quality Forum. About us. Available at: http://

www.qualityforum.org/about. Accessed June 30, 2008.

2. National Quality Forum. National Quality Forum updates

endorsement of Serious Reportable Events in Healthcare.

Available at: http://www.qualityforum.org/pdf/news/prSerious

ReportableEvents10-15-06.pdf. Accessed June 30, 2008.

3. American Medical Association. No pay for ‘‘never event’’

errors becoming standard. Available at: www.ama-assn.org/

amednews/2008/01/07prsc0107.htm. Accessed June 30, 2008.

4. Modern Healthcare. Michigan association sets ‘‘never

events’’ policy. Available at: http://www.modernhealthcare.

com/apps/pbcs.dll/article?AID5/20080626/REG/997311079.

Accessed June 30, 2008.

5. Centers for Medicare and Medicaid Services. Incorporating

selected National Quality Forum and never events into Medi-

care’s list of hospital-acquired conditions. Available at: http://

www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter5

3043&intNumPerPage510&checkDate5&checkKey5&srchType

51&numDays53500&srchOpt50&srchData5&srchOpt50&

srchData5&keywordType5All&chkNewsType56&intPage

5&showAll5&pYear5&year5&desc5&cboOrder5date. Ac-

cessed June 30, 2008.

6. The Leapfrog Group. Fact sheet: Never events. Available

at: http://www.leapfroggroup.org/media/file/Leapfrog-Never_

Events_Fact_Sheet.pdf. Accessed July 1, 2008.

7. The National Quality Forum. Serious reportable events in

healthcare 2006 update. Available at: http://www.qualityforum.

org/pdf/reports/sre/txsreexecsummarypublic.pdf. Accessed

July 1, 2008.

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