The prevention of health care-acquired conditions (HACs), also known as “never events,” is a critical goal for health care organizations. The Center for Medicare and Medicaid Services (CMS) has identified a list of HACs that are considered preventable through the application of risk management strategies. This paper will discuss the actions that health care organizations have implemented to manage or prevent these never events from occurring within their facilities. The discussion will be supported by two peer-reviewed articles that demonstrate the effectiveness of these actions.
Actions Implemented by Health Care Organizations
Health care organizations have implemented various actions to manage or prevent never events from occurring within their facilities. These actions can be broadly categorized into three key strategies: standardization and guidelines, staff training and education, and performance monitoring and feedback.
Standardization and Guidelines: One of the key actions undertaken by health care organizations is the establishment of standardized protocols and guidelines. These protocols outline best practices and evidence-based guidelines that aim to prevent never events. For example, the implementation of surgical safety checklists has been widely adopted to reduce surgical site infections and wrong-site surgeries. A study conducted by De Vries et al. (2015) examined the impact of implementing a surgical safety checklist in a multidisciplinary hospital in the Netherlands. The study found that the checklist significantly reduced the occurrence of surgical site infections and wrong-site surgeries. This highlights the effectiveness of standardized protocols in preventing never events.
Furthermore, health care organizations have developed guidelines for the prevention of other never events, such as pressure ulcers and catheter-associated urinary tract infections. These guidelines focus on risk assessment, prevention strategies, and appropriate interventions. For instance, a study by Padula et al. (2018) evaluated the implementation of a pressure ulcer prevention program in a hospital setting. The program included risk assessment, regular repositioning, and the use of proper support surfaces. The study demonstrated a significant reduction in the incidence of pressure ulcers, indicating that adherence to standardized guidelines can effectively prevent never events.
Staff Training and Education: Another important action undertaken by health care organizations is the provision of comprehensive training and education to healthcare professionals. Training programs are designed to enhance the knowledge and skills of healthcare providers in identifying and preventing never events. For example, surgical teams receive training on surgical site infection prevention, including appropriate antisepsis techniques and the use of prophylactic antibiotics. A study by Gillespie et al. (2017) evaluated the impact of an educational intervention on the adherence to infection control practices among surgical teams. The study found that the intervention significantly improved compliance with infection control protocols, leading to a decrease in surgical site infections. This highlights the importance of ongoing education and training in preventing never events.
In addition to healthcare providers, patients are also educated about self-care and prevention strategies to reduce the risk of never events. For instance, patients may receive education on preventing falls, such as using handrails and wearing appropriate footwear. A study by Barker and Watkins (2016) explored the effectiveness of a patient education program on fall prevention in a hospital setting. The results showed a significant reduction in fall-related injuries after the implementation of the program, suggesting that patient education plays a crucial role in preventing never events.
Performance Monitoring and Feedback: Health care organizations employ performance monitoring and feedback systems to identify and address potential risks and gaps in care. The collection and analysis of data related to never events allow organizations to identify trends, assess their own performance, and implement targeted interventions. For example, organizations may track the rates of catheter-associated urinary tract infections and implement measures to reduce these rates. A study by Metersky et al. (2014) assessed the impact of a performance feedback initiative on reducing catheter-associated urinary tract infections in hospitals. The study found a significant decrease in infection rates after the implementation of the feedback system, indicating the effectiveness of monitoring and feedback in preventing never events.
Furthermore, health care organizations also utilize root cause analysis (RCA) to investigate the underlying causes of never events and implement preventive measures. RCA involves a systematic approach to identify and address the root causes of adverse events. For example, if a wrong-site surgery occurs, an RCA may reveal flaws in the preoperative verification process or communication breakdowns among the surgical team. By addressing these underlying causes, health care organizations can prevent the recurrence of never events.
Health care organizations have implemented various actions to manage and prevent never events from occurring within their facilities. These actions include the establishment of standardized protocols and guidelines, comprehensive staff training and education, and the implementation of performance monitoring and feedback systems. The effectiveness of these actions in preventing never events is supported by the findings of peer-reviewed studies. By adopting these strategies, health care organizations can improve patient safety and provide high-quality care.