The Center for Medicare and Medicaid Services (CMS) publishes a list of health care-acquired conditions (HACs) that reasonably could have been prevented through the application of risk management strategies. What actions has your health care organization (or have health care organizations in general) implemented to manage or prevent these “never events” from happening within their health care facilities? Support your response with a minimum two peer-reviewed articles.
The Centers for Medicare and Medicaid Services (CMS) produces a list of healthcare-acquired conditions (HACs) that limit its reimbursement to institutions that make efforts to reduce or prevent “never events.” According to the National Quality Forum (NQF), “never events” denote to a host of adverse events that should have never occurred in the first place if a health facility and its providers had safety and risk management measures to enhance patient care (PSNet, 2019). These events include hospital-acquired pressure ulcers, foreign object intrusion, wrong-site surgery and wrong patient surgical operation, and medication errors among others (AAACN, 2022). These serious reportable events should not happen when hospitals and facilities implement safety measures that include the following.
Establishment and emphasis on safe practice and having a safety protocol allow providers to develop safety plans and manage patients better. Through these protocols, the staff becomes aware of the expected standards and procedures as well as the type or personal protective equipment needed to enhance patient safety (Anderson & Watt, 2020). Secondly, identification and prevention of risks is critical as it ensure that the facilities can mitigate their occurrence and lead to the provision of patient protection and compliance. Thirdly, staff education and training are a critical component of ensuring that they understand the quality measures and approaches to prevent any adverse event from taking place in their facilities.
Fourthly, proper documentation of all events, records and history is essential in ensuring that staff learn from the past events and develop evidence-based practice interventions to ensure that they do not occur again (AAACN, 2022). Hospitals should have risk management teams and personnel to implement quality improvement initiatives aimed at improving compliance for providers and patients. The implication that “never events” have negative effects on the quality of care and reimbursement process.
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American Academy of Ambulatory Care Nursing (AAACN) (2022). Prevention and Early
Detection of “Never Events” Within Ambulatory Settings to Enhance Quality and Safety and Prevent Financial Losses. https://www.aaacn.org/prevention-and-early-detection-never-events-within-ambulatory-settings-enhance-quality-and-safety
Anderson, J. E., & Watt, A. J. (2020). Using Safety-II and resilient healthcare principles to learn
from Never Events. International Journal for Quality in Health Care, 32(3), 196-203. DOI: 10.1093/intqhc/mzaa009.
Centers for Medicare and Medicaid Services (CMS) (2021 December 1). Hospital-Acquired
Patient Safety Net (PSNet) (2019 September 7). Never Events.
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