'Never event' and preventable patient harm data: 10 challenges, recommendations

Lapses in patient safety are a major quality problem in healthcare, leading to more than 200,000 deaths, 2.4 billion extra hospital days and between $17 billion and $29 billion in excess hospital costs in the U.S. each year, according to an article from The Joint Commission Journal on Quality and Patient Safety.

"'Never Events' and the Quest to Reduce Preventable Harm" was authored by J. Matthew Austin, PhD, assistant professor at the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine in Baltimore, and Peter J. Pronovost, MD, PhD, senior vice president of patient safety and quality of Johns Hopkins Medicine.

According to the authors, never event data is crucial to identifying challenges and working to prevent patient harm.

"To realize the total eradication of never events, we need a better and more accurate mechanism for measuring and reporting them," wrote the authors.

Highlighted below are 10 challenges of collecting never event data and preventing patient harm, as well as recommendations suggested by Dr. Austin and Dr. Pronovost.


1. Discrepancies in how a never event is defined leads to confusion when trying to collect and use never event data. For instance, the National Quality Forum, CMS and private insurers all use different definitions, including "a serious reportable event" or "a nonreimbursable healthcare-associated infection."

2. Establishing preventability and the degree to which an event must be fully preventable for it to be categorized as a never event is also challenging. Most entities recognize that not all events are fully preventable but drawing the line between what should and should not be considered preventable is not easy.

3. The lack of transparency and required public reporting of these events also makes collecting data difficult. While many states have taken the lead on reporting such data, often without identification of individual hospitals, there is no standardized national reporting system to provide information on the number and type of adverse events, even for the most serious and preventable errors.

4. Another challenge is the concern over the accuracy of never event data derived from administrative data relative to chart review. The more hospitals have to focus on improving data and coding, the less they can focus on caring for patients.

5. Timeliness of never event data also poses a problem. Frequently, there is an 18-month, or even longer, lag between an event and its public reporting, which limited the value for feedback to clinicians and quality and safety professionals.


6. Policy makers and Patient Safety Organizations should agree upon a standardized definition of a never event and there should be a mechanism to require reporting entities to use it.

7. The healthcare community should establish standards for the accuracy of never events derived from administrative data, relative to chart review, and publicly report the accuracy of these metrics.

8. The number of never events should be reported transparently to provide a comprehensive picture of the types of events occurring, where they are occurring and the impact they have on patients.

9. Healthcare policy makers, insurers, providers and patients should create mechanisms to share best practices for reducing all types of never events, such as clinical communities where hospitals can collaborate.

10. Once the above measures have been accomplished, hospitals should be held accountable for eliminating never events through economic incentives and sanctions.



More articles on patient safety:
Patient Safety Movement tackles preventable patient deaths with innovation contest
12 California hospitals penalized for patient safety issues
UTHealth to establish biosafety and infectious disease training program


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