Never Events and Universal Protocol Top Hospital’s Patient Safety Priority List

By Charles F. Bombard, RN, MHA, CPHQ, FACHE

Hospitals are places of great skill, technology, and healing. But they are also prime sources of potentially life-threatening medical errors. The key to preventing medical errors is for clinical and administrative leaders to give patient safety issues the highest priority.

Two issues in patient safety at the top of many hospitals’ quality and patient safety priority list are “never events” and the Universal Protocol. The term “never events”, introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the term expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.

The National Quality Forum initially defined 27 such events in 2002 and revised and expanded the list to 28 in 2006. Because “never events” are devastating and preventable, healthcare organizations are under increasing pressure to eliminate them. In August 2007, the Centers for Medicare and Medicaid Services announced that Medicare would no longer pay for the treatment of many preventable errors, including never events, pressure ulcers, air embolism, blood incompatibility, object left in after surgery, and patient falls.1 It’s anticipated that the list of never events for which Medicare will withhold reimbursement will grow. Other insurers are also refusing to pay hospitals for never event errors.

Some Gannett Education CE courses that relate to the never events issue include:

CE 498: Promoting a culture of safety to prevent medical errors
CE 549: Safety first: The Joint Commission National Patient Safety Goals, 2009
CE 481: A perfect match: Preventing blood incompatibility errors
CE 80-60f and CE 81-60f: Wound care, parts 1 and 2
CE 151-60e: Fall prevention among the elderly

The second issue relates to the Universal Protocol, the process intended to prevent wrong-site surgery and, if carried out correctly, ensures the right patient, right procedure, and right site for all applicable procedures, i.e., operative or invasive procedures that expose the patient to more than a minimal risk. The Universal Protocol was one of the first Joint Commission National Patient Safety Goals, with hospitals required to be in compliance by Jan. 1, 2004. While the Universal Protocol, with its requirements for verification, site marking, and a time-out immediately before initiating a procedure, has been effective, it has not had the impact on reducing wrong-site surgery that was anticipated. In 2009, to increase the effectiveness of the Universal Protocol, the Joint Commission intensified the requirements for compliance. Some of the additional expectations include verification of the correct patient, procedure, and site at the time of preadmission testing/assessment. The site marking requirement has expanded to mandate the surgeon (for OR cases) or proceduralist (for non-OR cases) to mark the site before the patient is moved to the location of the procedure. This same practitioner must to be present for and directly involved in the procedure. New requirements for the time-out portion include making sure the patient is properly positioned for the procedure and that the informed consent is consistent with the proposed procedure.

2 Gannett Education CE courses that address wrong-site surgery and operative medical errors include:

CE 495: What’s being done to prevent wrong-site surgery
CE 466: Take aim at medical errors by creating a culture of safety in the OR

References:

Agency for Healthcare Research and Quality: Never Events. www.ahrq.gov Website.
The Joint Commission. 2009 Hospital Accreditation Standards