Clarifying "never events" and introducing "always events"

Lembitz, Alan; Clarke, Ted J.

doi:10.1186/1754-9493-3-26

Cited by 78 publications

(70 citation statements)

References 9 publications

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“…18 This has raised concerns that patients experiencing complications listed as nonreimbursable serious hospital acquired conditions will be inaccurately told that those never events are based on negligence or medical errors, leaving medical practitioners open to the attendant risk of litigation for negligence. 19 The limitation of the study is that there was a lack of a concurrent comparison group with the intervention group. Although the study settings are similar and measurement bias has been effectively taken care of since the present study was done on the same lines as the previous one with which the results are being compared.…”

Section: Discussionmentioning

confidence: 99%

Control of hospital acquired infections in the ICU: A service perspective

Goyal¹,

Ramesh²,

Ravishankar³

et al. 2015

Medical Journal Armed Forces India

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Hospital acquired infectionsCatheter related blood stream infection Ventilator-associated pneumonia Catheter associated urinary tract infection a b s t r a c t Background: The service setting has some unique strengths and weaknesses that must be kept in mind when organizing Hospital acquired infections (HAI) prevention interventions.Methods: Following an initial study to gather data regarding HAI in the Surgical intensive care unit (ICU) we put into place various infection control interventions. The present study was carried out to analyse the effect of these interventions on the incidence of HAI in the ICU. Results:The total admissions to the ICU were 253 patients. Eighty eight patients (34.78%) were admitted for more than 48 hr, 165 patients stayed for less than 48 h. The frequency of HAI was 7.95% (95% CI 3.54, 15). Hospital acquired pneumonia was observed in 2 of the 88 patients (2.27%) (95% CI 0.38, 7.30) which amounted to 9.70 infections per 1000 ventilator days. Bloodstream infection was detected in 3 out of 88 patients (3.4%) (95% CI 0.87, 8.99) amounting to 6.54 fresh infections per 1000 Central Venous Catheter days. Urinary tract infection was observed in 2 (2.27%) (95% CI 0.38, 7.30) at 2.86 fresh infections per 1000 catheter days. As compared to the previous study we found that there was a decline of HAI ranging from 60 to 70%. Conclusion:Our study demonstrated that by meticulously following infection control protocols especially tailored to the service setting the incidence of HAI's can be reduced.However, the challenge is in maintaining the gains achieved since there is a rapid turnover of manpower in the ICU and a lack of a structured ICU design model. © 2014, Armed Forces Medical Services (AFMS). All rights reserved.* Corresponding author. E-mail address: sshivinder@hotmail.com (S. Singh). m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 2 8 e3 2http://dx

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Section: Discussionmentioning

confidence: 99%

Control of hospital acquired infections in the ICU: A service perspective

Goyal¹,

Ramesh²,

Ravishankar³

et al. 2015

Medical Journal Armed Forces India

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“…The list includes obvious unacceptable errors. However, not all the events are indicative of obvious negligence 2 . A goal of quality improvement is to reduction of never events to zero.…”

Section: Introductionmentioning

confidence: 99%

“…The quality and safety of patient care in hospitals are important aims of National Quality Forum (NQF) in the US 1,2 . Never Event (NE) and Hospital Acquired Conditions (HAC) as adverse serious events that are largely preventable are reliable measurements of the quality and safety of patient care 1,2 .…”

Section: Introductionmentioning

confidence: 99%

“…Never Event (NE) and Hospital Acquired Conditions (HAC) as adverse serious events that are largely preventable are reliable measurements of the quality and safety of patient care 1,2 . NE and HACs also have a significant financial impact on the US healthcare system 3 .…”

Section: Introductionmentioning

confidence: 99%

“…NE was defined by National Quality Forum (NQF) in 2006 which includes 28 reportable events in healthcare 2 . The list includes obvious unacceptable errors.…”

Section: Introductionmentioning

confidence: 99%

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Never events and hospital-acquired conditions after kidney transplant

Moghadamyeghaneh

Chen

Alameddine

et al. 2017

CUAJ

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Introduction: Never events (NE) and hospital-acquired conditions (HAC) after surgery have been designated as quality metrics in healthcare by the centres for Medicare and Medicaid Services (CMS). Methods: The Nationwide Inpatient Sample (NIS) database 2002-2012 was used to identify patients underwent kidney transplant. Multivariate analysis using logistic regression was used to identify outcomes and risk factors of HAC and NE after transplantation; however, we were limited by using a retrospective database missing some important variables specified for the kidney transplant, such as some operative factors, donor factors, and cold and warm ischemia times. Results: Among 35 058 patients who underwent kidney transplant, there were 11 NEs, all of which were due to retained foreign bodies. Among HAC after surgery, falling was the most common (44.9%), followed by poor glycemic control (21.7%), vascular catheter-associated infection (21%), and catheter-associated urinary tract infection (8%). HAC and NE after surgery lead to a significant increase in mortality (adjusted odds ratio [AOR] 2.49; p=0.04), hospitalization length (13 vs. 7 days; p<0.01), and total hospital charges ($231 801 vs. $146 717; p<0.01). A significantly higher risk of HAC or NE was seen for patients who had more loss of function before surgey (AOR 3.25; p<0.01) and patients expected to have higher postoperative mortality before operation (AOR 1.62; p=0.03).

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