dicussion
Lisa Marie Sinotte
Walden

Discussion
Never events are the kind of events that should never happen in healthcare. These “never events” are defined as preventable adverse events by The Centers for Medicare and Medicaid (http://www.cms.gov/). Starting in 2008, The Centers for Medicare and Medicaid Services eliminated or reduced payments for certain “never events” (Thornlow & Merwin, 2009). The Centers for Medicare and Medicaid requires hospitals to report claims for discharges and whether or not selected conditions were present on admission. If a condition is acquired in a hospital, Medicare will not cover the cost of the acquired condition. This “Pay for Performance” initiative highlights the importance of following performance standards to decrease or eliminate “never events”.
Preventing patient falls is a universal issue and a “never event”. Falls, and injuries from falls for hospital inpatients are the most frequent adverse events reported (http://www.nursingworld.org). With global emphasis to provide safe quality care, there in now increased scrutiny and inspection for the assessment of falls. The Joint Commission requires accredited hospitals to conduct fall risk assessments so that prevention methods can be implemented into the patient’s plan of care. The National Database of Nursing Quality Indicators allows organizations to compare injury fall rates so that participating hospitals can evaluate the efficacy of their processes, clinical effectiveness of the staff, and the usefulness of fall assessment programs. Quality indicators link nursing care to patient outcomes (http://www.nursingworld.org). These quality indicators provide on-going evaluation and measurement of performance and can identify were modifications may be needed.
The insurgence of the requirements of The Centers for Medicare and Medicaid and The Joint Commission impacts