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Unfinished Work

In: Other Topics

Submitted By xraytech17
Words 444
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Ken Kizer MD. coined the term “never events” in 2001 referring to medical mistakes that should never occur (wrong surgery site). The National Quality Forum categorizes never events into six groups: surgical, product or device, patient protection, care management, environmental, and criminal. For a never event to fit into one of the categories never events must be serious in its result (death or significant disability), unambiguous (clearly identifiable and measurable), and usually preventable("AHRQ Patient Safety Network - Never Events," 2011). As of 2006 there are currently 28 “never events” which include unintended retention of a foreign object in a patient after surgery or other procedure, intra-operative or immediately post-operative death in an ASA Class I patient and surgery performed on the wrong body part ("AHRQ Patient Safety Network - Never Events," 2011).

In most states there is no mandatory reporting of never events, event though some estimates put national incident rate as high 40 per week. This includes wrong patient and wrong site. Eight hospitals and ambulatory surgical centers in the United States recognized that never events are a critical part of patient safety issues a critical patient safety ("The Joint Commission Center for Transforming Healthcare |Newsroom," 2011). The healthcare facilities joined the Joint commission center for Transforming Healthcare to address the problem. There are currently 25 states and the District of Columbia have mandatory reporting, only a few of them publicly report never events ("Fact Sheet: Never Events," 2011).
On January 1, 2007 SB 1301, Chapter 647 is an act to add Section 1279.1, 1279.2,
1279.3 and 1280.4 to, the Health and Safety Code, relating to health facilities. The law mandates hospitals to report adverse events the California Department of Health (DHS) within five days. However, of the event is an urgent or emergency threat to the health or safety of a patient then the report must occur with in 24 hours.

1, J. (n.d.). Article 3. Regulations :: California Health and Safety Code :: 2009 California Code :: California Code :: US Codes and Statutes :: US Law :: Justia. US Law, Case Law, Codes, Statutes & Regulations :: Justia Law. Retrieved July 8, 2011, from

AHRQ Patient Safety Network - Never Events. (2011). AHRQ Patient Safety Network. Retrieved July 7, 2011, from

Fact Sheet: Never Events. (2011, March 29). THE LEAPFROG GROUP. Retrieved from

The Joint Commission Center for Transforming Healthcare | Newsroom. (2011, June 29). The Joint Commission Center for Transforming Healthcare - Home. Retrieved July 9, 2011, from

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