The article by Watson (2010) is dedicated to never events, which are also called serious reportable events. These are the cases that should never occur during medical operations. The article also describes the actions of the National Quality Forum (NQF) aimed at preventing the never events.
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NQF has confirmed a list of serious reportable events that includes 27 never events. Later the list was expanded to 28 events that should be prevented by medical personnel. This list aims to increase the awareness of medical doctors and nurses and to increase the transparency of the health care system, as in some states reporting on these events is mandatory. Pennsylvania and Minnesota are the states that mandate the reporting of never events. Besides, the measures aimed at preventing these events are implemented. For example, an initiative on counting the sponges and sharps was encouraged, which should exclude forgetting the foreign objects in the bodies of patients.
The Centers for Medicare and Medicaid Services have suggested reducing the payment for predictable never events. Predictable complications which should be considered during operation include, for example, air embolism, blood incompatibility, retained foreign body after surgery, and pressure ulcer. In 2009, such conditions were added to the list as surgical site infections, deep vein thrombosis or pulmonary embolism after knee replacement, and poor control of blood sugar levels (Watson, 2010). Besides, the physicians are not supposed to receive payment for such egregious events concerning operating on the wrong patient, wrong procedure, and surgery on the wrong body part.
The Leapfrog Group, established in 2000, offered a list of initiatives that are supposed to improve the quality of healthcare. For example, a hospital should waive charges for the operation associated with the never event, a Joint Commission should monitor the healthcare services, and so on. All in all, such initiatives are aimed at promoting the culture of safety and awareness of healthcare personnel.
Watson, D. S. (2010). Never events in healthcare. AORN Journal, 91(3), 378—381.