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Reducing 'never events' in healthcare

May 29, 2015

The Joint Commission Resources (JCR) has published a new document to further raise awareness about the importance of reducing so-called 'never events', such as needlestick injuries, for healthcare workers.

The latest Joint Commission Journal on Quality and Patient Safety features an article entitled 'Never Events' and the Quest to Reduce Preventable Harm. 'Never events' encompasses a wide range of incidents that are deemed to be unacceptable in modern healthcare. 

Including incidents such as wrong-site surgeries, patient suicides, the unintended retention of a foreign object in a patient after surgery, and needlestick injuries, the article highlights how these 'never events' can be better controlled.

Using findings from adverse events, serious reportable events, sentinel events and patient safety events, healthcare managers can help to reduce the number of these type of avoidable events in their own hospital or medical setting. These, according to the report, can also have an impact on patient care and ensuring that the standard remains high.

Written by a number of leading experts from the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, the report discusses how the process of collecting data has evolved regarding never events.

It also suggests a number of recommendations for how it can be further improved, and help to control and reduce the number of incidents that occur in hospitals.

According to the article, policymakers should work alongside patient safety organisations to agree on standard definitions of never events, while the wider healthcare community needs to establish standards for the accuracy of never events derived from administrative data, relative to chart review, and publicly report the accuracy of these measures. 

In addition, the number and severity of never events should be transparently reported, much like the state of Minnesota has done for more than a decade, and healthcare policymakers, insurers, providers and patients should create mechanisms to share best practices for reducing all types of never events, the report states.

Authors Dr Matthew Austin and Dr Peter J. Pronovost from the Armstrong Institute for Patient Safety and Quality said never events are happening with "a troubling frequency".

They said many of these events, such as wrong-patient surgery, are deemed to be ‘fully preventable’.

"If we hope to see reductions in the frequency of these events, we need to change the decade-long decentralised approach of collect, report and improve to an approach that entails standardised definitions of events, greater transparency of performance, and collective learnings and accountability to drive performance forward,” the authors concluded.

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