2023 Comment1 The National Quality Forum NQF published a report on 27 adverse events

Comment1

The National Quality Forum (NQF) published a report on 27 adverse events that were serious and preventable, “Never Events”.  In 2008, Medicare stopped payments to hospitals for any additional care needed resulting from 11 of the 28 “Never Events.”  These 11 conditions were identified by the NQF as patient safety events that are entirely preventable.  These “never events” for which hospitals no longer receive Medicare reimbursement include the following: 

1. Surgical-site infections after certain orthopedic and bariatric surgeries

2. Blood incompatibility 

3. Pressure ulcers

4. Vascular catheter-associated infection 

5. Deep-vein thrombosis or pulmonary embolism after total knee and hip replacements 

6. Falls/trauma 

7. Objects left in pt during surgery 

8. Catheter-associated urinary tract infection 

9. Air embolism 

10. Surgical-site infections after coronary artery bypass graft 

Comment2

CMS reimbursement rules regarding never events forced changes in the hospitals and methods of caring for patients in positive ways. While the term “never events” was coined by advocacy groups, CMS refers to these types of events as “reasonably preventable by following evidence-based guidelines” (Lembitz & Clarke, 2009). This indicates that sometimes, even if the best of care is delivered, patients may still develop complications like DVTs, CAUTIs, CLABSIs, and the like. However, it is less likely that these events will occur if the practitioners follow the most recent evidence based practices for prevention. For instance, starting patients on heparin, early mobilizations, and wearing SCDs after surgery to prevent a DVT instead of allowing the patient to lay around all day. When CMS altered their reimbursement protocols, it forced hospitals to enforce the following of safety protocols and checklists by those delivering care to minimize the occurrence of these events. While, sadly, money was the motivator in order for this to come to fruition, it cannot be denied the positive impact it has had on patient care.