Examples of “Never Events” and Their Impact

The Centers for Medicare & Medicaid Services (CMS) formed its no-pay policy based on the growing work of National Quality Forum (NQF) of “never events.” Meaning, CMS will no longer pay for certain conditions that result from what might be termed poor practice or events that should never have occurred while a patient was under the care of a healthcare professional.

Discuss specific examples of “never events” and their impact in your workplace.

What issues are you considering for your clinical project and why?

The Centers for Medicare & Medicaid Services (CMS) “no-pay” policy, aligned with the National Quality Forum’s (NQF) list of never events, represents a pivotal shift in healthcare reimbursement and quality improvement. These “never events” are serious, preventable, and costly errors that should never occur in a healthcare setting. By refusing to reimburse hospitals for the costs associated with these errors, CMS encourages higher standards of care and accountability.

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Examples of “Never Events” and Their Impact in the Workplace:

1. Pressure Ulcers (Stage III or IV):

   • Impact: Pressure injuries are largely preventable through timely repositioning, skin assessments, and moisture management. When these ulcers develop under hospital care, it often reflects breakdowns in nursing care planning or staffing issues.

   • Workplace Effect: Increased documentation, pressure injury prevention bundles, and the adoption of technologies like pressure-sensing mattresses have been implemented. It also leads to heightened staff training and multidisciplinary rounding to ensure early detection.

2. Falls with Injury:

   • Impact: Patient falls, especially those resulting in fractures or head injuries, are a major concern in acute care. Falls can extend hospital stays and result in long-term disability.

   • Workplace Effect: Facilities have introduced hourly rounding, bed alarms, non-slip socks, and individualized fall risk assessments. Despite these measures, underreporting and staff fatigue can still lead to incidents.

3. Surgical Instruments Left in Body After Surgery:

   • Impact: Retained surgical items (RSIs) are rare but critical errors that can cause serious infections or require additional surgeries.

   • Workplace Effect: Mandatory surgical counts, surgical time-outs, and newer radiofrequency-detection technologies are now standard. Operating rooms enforce strict adherence to safety protocols.

4. Catheter-Associated Urinary Tract Infections (CAUTIs):

   • Impact: CAUTIs are common in hospitalized patients and largely preventable. They can lead to prolonged stays and additional antibiotic use.

   • Workplace Effect: Implementation of catheter bundles, nurse-driven protocols for early removal, and better hygiene practices have reduced CAUTI rates. However, compliance remains an ongoing challenge.

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Issues Being Considered for My Clinical Project:

Topic: Reducing Hospital-Acquired Infections (HAIs) through Improved Hand Hygiene Compliance

Why This Topic:

1. Relevance to Never Events and CMS Policy:

   • Poor hand hygiene is a major contributing factor to many HAIs, including CAUTIs, central line-associated bloodstream infections (CLABSIs), and surgical site infections (SSIs), all of which may fall under CMS scrutiny for non-reimbursement.

2. Observed Challenges in Practice:

   • Despite awareness campaigns and availability of sanitizers, hand hygiene compliance is often below target—due to high workloads, forgetfulness, or lack of accountability.

   • Audits show that healthcare professionals, including nurses and physicians, do not consistently follow hand hygiene protocols between patient interactions.

3. Potential for High Impact:

   • Even modest improvements in compliance can significantly reduce infection rates.

   • It’s a low-cost, high-yield intervention that aligns with patient safety goals and improves care quality metrics.

4. Opportunities for Interdisciplinary Collaboration:

   • The project would involve education, auditing, feedback loops, and potentially technology (e.g., electronic hand hygiene monitoring systems), creating a comprehensive and sustainable intervention.

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Summary:

Never events have reshaped how care is delivered, placing quality and safety at the center of healthcare practice. In my workplace, these events have prompted systemic changes—from stricter protocols to technological upgrades. For my clinical project, I am focusing on a foundational yet often overlooked issue: hand hygiene. By targeting this root cause, I hope to contribute to a culture of safety and compliance that aligns with CMS standards and enhances patient outcomes.