Never Event Essay

1018 Words5 Pages
“Never events” and hospital-acquired conditions are two terms used to identify highly preventable and substantially serious medical errors or conditions that occur during hospital stay. Error reduction and improvement of healthcare systems remain a top priority of many national organizations and agencies that aim to decrease and prevent such incidences from happening. Consequences of these errors are high and can affect patient health, hospital accreditation, and nurse licensure. As a result, hospitals and nurses are continually implementing and practicing evidenced-based safe practices in a nationwide effort to reduce, minimize, and ultimately eliminate “never events”. “Never events” are also known as “serious reportable events” (SREs), an official term adopted and used by the National Quality Forum (NQF). The NQF defines SREs as events that should never have occurred to the patient when receiving care in a hospital. SREs are viewed as identifiable events that cause substantial harm to the patient and are almost always preventable. (Lembitz, 2010, pg. 30) Examples of “never events” include, but are not limited to the following: • Death due to administration of wrong medication • Wrong surgery procedures conducted on the wrong patient and/or wrong body part • Patient abduction • Handing an infant patient to the wrong person during discharge NQF has compiled a list of 28 “never events” that is used in many states across the nation. These states, along with the Joint Commission, require such events to be reported by hospitals within a timely manner after an incident. Along with the report, a root cause analysis is required to determine the pattern of error(s) that contributed to the “never event” in hopes of improving health care systems, and thereby, preventing further occurrences. Efforts to increase accountability and prevent future errors
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