Background Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities. Introduction When first introduced, there were only 27 specific situations classified as never events, but now the list has been expanded to contain 29. These events have been classified into 6 different categories: criminal, radiologic, surgical, environmental, care management, patient protection, and product or device ... ... middle of paper ... ...of unintentionally retained foreign objects during vaginal deliveries. (2012, January). Retrieved from ICSI.org: https://www.icsi.org/_asset/3xvmi8/RFO.pdf The Joint Commission. (2013, October 17). Preventing unintended retained foreign objects. Retrieved from www.jointcommission.org:http://www.jointcommission.org/assets/1/6 /SEA_51_URFOs_10_17_13_FINAL.pdf The Joint Commission. (2013, August 1). Summary data of sentinel events reviewed by the joint commission. Retrieved from JointCommission.org:http://www.jointcommission.or g/sentinel_event.aspx US Department of Health and Human Services. (2012, October). Never Events. Retrieved from AHRQ.gov: http://psnet.ahrq.gov/primer.aspx?primerID=3 AORN. (2013). Policy profile: The perioperative registered nurse circulator. Retrieved from www.aorn.org: file:///C:/Users/Klarissa/Downloads/Policy%20Profile.pdf
Explain the issue or dilemma using information from the readings in the book and other sources.
Chasing Zero is a documentary which was meant to both educate the viewer on the prevalence of medical harm as well as to enlighten both the public and health care providers on the preventability of these events (Discovery, 2010). The documentary expounded on the fact each year more people die each year from a preventable medical error than die due to breast cancer, motor vehicle accidents or AIDS (Institute of Medicine, 1999). Medical harm can result from adverse drug events, surgical injuries, wrong-site surgery, suicides, restraint-related injuries, falls, burns, pressure ulcers and mistaken patient identities (Institute of Medicine, 1999). Incidences of medical error have been reported in the media for many years. The most startling revelation in the documentary is how common medical errors are and how preventable they are.
The concept of risk management is relatively new, as hospitals look to prevent hospital-acquired infections (HAIs), falls, injuries, and other forms of preventable harm, rather than reacting once harm has already taken place. Before this concept became a best practice, most health organizations relied on malpractice and liability insurance to protect against losses and mitigate the effects of accidents and poor patient outcomes (Colorado State University-Global Campus, 2014). Today, risk management is an integral facet of a healthcare facility’s business practice in preventing risks, ensuring regulatory compliance, minimizing financial damage, and preserving its reputation in the community. Although most large
There is nothing traumatizing in the world has adding pain to where it already exists. This is the hell situation which every medical error victim is exposed. As the statistics are currently showing, the fatalities are increasing day by day. The trend seems to be hiding on the old ideology of “man is to error”. However this is not being tolerated any more and the American medical facilities are being held 100% accountable for the mistakes they make in their service delivery. Professional diligence is not a matter of negotiation in this generation and probably future generations. If a medical facility cannot treat people diligently, then the only better option remaining for that facility is to be made to account for the losses they have caused on affected patients and be closed down immediately.
In order for hospitals to be reimbursed from government based insure companies certain standards must be met. When standards are not met, any subsequent cost in relationship to preventable errors will not be remunerated (Youngberg, 2011). These preventable errors are termed never events. Never events are considered error that can be prevented if certain checklist and guidelines are in place are followed such as medication errors, falls with injury, wrong surgical site, and pressure ulcers (Agency for Healthcare Research and Quality, 2012). There are currently ten mandated never events (Youngberg, 2011). In order to avoid these preventable human errors, risk manager help implement policies and procedure. This process based on risk analysis and outcomes which helps to improv...
Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission published their National Patient Safety Goals. Among the goals was the Universal Protocol. The Universal Protocol is actually drawn from several of the National Patient Safety Goals. It relies on multiple check points and the involvement of the entire surgical team to avoid such errors. Wrong site, wrong procedure, and wrong patient surgeries should never happen. The Universal Protocol is an evolving process which reflects the success and failures of healthcare practice, thus it requires periodic updates and policy revisions.
In saying 1.5 million Americans have witnessed hospital errors in the care of the medical center or even 40,000-100,000 deaths is a ridiculous amount of faults. Errors should be minimized, especially when dealing with people’s lives. The number of deaths is so high hospitals should take notice and really pinpoint where their facility is miscalculating and create in-service training to all employees and not just the ones that are making the errors but all employees. This will decrease the chances of errors made in the hospital. With continuous training every month there can be a huge change in the number of mistakes. The fact that these inaccuracies are even causing deaths really highlight the importance of the need for a change. Families
In the United States, hospitals and organizations find ways to help prevent events that should rarely or never occur, often called Never Events. The list of Never Events is made in order to provide hospitals with incentives to make sure the occurrences of them are reduced. As Mrs. Friend states, “If revenue decreases in our health care facilities because of “Never events” this could impact nursing in many ways. The rate of pay, staff to patient ration, availability of modern medical equipment, and our health insurance premiums will all be affected” (Friend, 2009, p. 5). One major type of Never Event that happens more often than it should is a surgical never event. Although, the occurrences of surgical Never Events may not be out of control, we must take into account that they are only reported if they are discovered. In today’s society the occurrence of Never Events should be virtually zero because of the technology available to prevent them.
Before starting this course and before reading the first section of Wall of silence: The untold story of the medical mistakes that kill and injure millions of Americans, I did not have much awareness of medical errors. My awareness extends to hearing stories about medical utensils and supplies being left in patients after surgery or hearing stories of patient receiving the wrong dose of medication, but hearing stories about the extent of deaths related to medical errors left me astonished. I was in awe reading the amount of deaths reported each year related to medical errors, not including the errors that are not reported. This book brings about the awareness and importance of implementing strategies to decrease medical errors.
The goal of patient safety is to prevent harm to patients Mitchell (n.d.). Patient safety in any health system is critical not only for the credibility of the system, but for patient trust and satisfaction as well. Adverse outcomes are defined as any injury or harm resulting from medical care (Watcher, 2008). Adverse outcomes can result in death and disability and cost the health system dearly. Bernard and Encinosa (2004) reported that in the U.S. it costs twice as much to care for patients that experienced adverse outcomes. The Institute of Medicine (IOM) (2000) reported that adverse outcomes cost the U.S. more than 16 billion dollars or 6% of total inpatient costs. Therefore, adverse events are costly both in terms of human life and fiscal resources.
Fierce healthcare reported sometime in June of 2012 that hospitals across the country had received safety report cards from one Leapfrog group. They reported that most facilities got a C or below in the rankings. The report also showed that the biggest hospitals such as the Henry Ford Hospital in Michigan barely got a passing grade. The report cards were meant to inform patients and also to motivate improvements in patient safety, they were faced with a lot of criticism and controversy especially from hospitals that did not pass. This paper will discuss the controversy facing patient safety in the U.S. It will also analyze the effects of the issue and the solutions suggested and currently in place to solve the issue.
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).
There is a group of surgical errors, which are believed to be completely avoidable. Since they are considered preventable, these mistakes are often referred to as surgical never events. This is because they should never happen. However, surgical never events do occur
The health care is extremely important to society because without health care it would not be possible for individuals to remain healthy. The health care administers care, treats, and diagnoses millions of individual’s everyday from newborn to fatal illness patients. The health care consists of hospitals, outpatient care, doctors, employees, and nurses. Within the health care there are always changes occurring because of advance technology and without advance technology the health care would not be as successful as it is today. Technology has played a big role in the health care and will continue in the coming years with new methods and procedures of diagnosis and treatment to help safe lives of the American people. However, with plenty of advance technology the health care still manages to make an excessive amount of medical errors. Health care organizations face many issues and these issues have a negative impact on the health care system. There are different ways medical errors can occur within the health care. Medical errors are mistakes that are made by health care providers with no intention of harming patients. These errors rang from communication error, surgical error, manufacture error, diagnostic error, and wrong medication error. There are hundreds of thousands of patients that die every year due to medical error. With medical errors on the rise it has caused the United States to be the third leading cause of death. (Allen.M, 2013) Throughout the United States there are many issues the he...
Many surgical errors are preventable. These types of mistakes are often referred to as never events, because it is widely held that they should never happen. However, surgical patients across the U.S. experience surgical never events approximately 80 times per week, according to American Medical News.