Conference for Pediatric Professionals 2008 : Conference for Pediatric Professionals 2008 Prevention of Never Events Presenters : Presenters Jennifer Emo, UTHSC Sydney Cronin, UTHSC Jennie Weaver, UTHSC Never Events : Never Events The National Quality Forum defines never events based on four criteria:
along with one of the following:
“indicative of a problem” in healthcare
“important for public credibility” from National Quality Forum (2006). Infant Discharged to Wrong Person : Infant Discharged to Wrong Person When a hospital discharges an infant to the wrong individual it is considered a never event.
This event typically occurs when a newborn is sent home with the wrong guardian after birth. Causes : Causes Human Error
-failure to comply with precautionary measures
-poor staff training
-identification compromised by non-hospital personnel Human Error : Human Error Failure to immediately provide identification upon delivery or admission
Failure to supply new identification when necessary
Failure to verify identification
-transportation inside hospital
-at time of discharge System Failure : System Failure Failure to provide adequate staff training
Failure to provide security measures to avoid outside interference Prevention Strategies : Prevention Strategies Hospital awareness
Additional identification systems From Raszl, I. From Zebra Importance : Importance Medicare and Medicaid will no longer pay for never event errors as of this year
Lawsuits and legal proceedings are costly to the hospital
Disciplinary action could come against hospital personnel involved
Loss of public credibility results with every occurrence Slide 10: Questions References : References Associated Press. (2008, April 13).Babies given to wrong families. The Hawk Eye. Retrieved August 15, 2008 from http://www.thehawkeye.com/Story/IL-Hospital-BabiesSwit-041308
Centers for Medicare & Medicaid Services. (2006). Eliminating serious, preventable, and costly medical errors- never events. Retrieved August 6, 2008, from http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863
Joint Commission on Accreditation of Healthcare Organizations. (2001). Front line of defense: The role of nurses in preventing sentinel events. Oakbrook Terrace, IL: Joint Commission Resources.
Joint Commission on Accreditation of Healthcare Organizations. (2008a). Infant abductions: Preventing future occurrences. Retrieved August 31, 2008, from http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_9.htm
Joint Commission on Accreditation of Healthcare Organizations. (2008b). Sentinel event statistics: as of June 30, 2008. Retrieved August 31, 2008, from http://www.jointcommission.org/NR/rdonlyres/241CD6F3-6EF0-4E9C-90AD-7FEAE5EDCEA5/0/SE_Stats_06_08.pdf
Lombardi, K. S. (1998, August 23). How hospitals keep babies linked to their parents. The New York Times. Retrieved September 1, 2008, from http://query.nytimes.com/gst/fullpage.html?res=9C0CE7DE123DF930A1575BC0A96E958260&sec=&spon=&pagewanted=all
National Quality Forum. (2006). Serious reportable events in healthcare 2006 update. Retrieved August 31, 2008, from http://sites.google.com/site/nsg505/never-events-resources/NQF-2006fullreport.pdf?attredirects=0 References : References National Quality Forum. (2008). Mission. Retrieved September 1, 2008, from http://www.qualityforum.org/about/mission.asp
Nguyen, T. (1999, February 16). Mistakes conceded in newborn mix-up. Los Angeles Times. Retrieved August 31, 2008, from http://articles.latimes.com/1999/feb/16/news/mn-8599
Powers, M. (1998, April 15). Failure to check baby ID suspected. The Commercial Appeal, p. A1.
Raszl, I. (2005). Paperwork. Retrieved September 14, 2008, from http://appleraszl.com/en/node/15
Wright, A. A., & Katz, I. T. (2005). Bar coding for patient safety. The New England Journal of Medicine, 353(4), 329-331.
Zebra Technologies Corporation. (2008). Wristbanding. Retreived September 14, 2008, from http://www.zebra.com/id/zebra/na/en/index/campaigns/emband10.htm?WT.srch=1