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: “unambiguous” “usually preventable” “serious” along with one of the following: “adverse” “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 System Failure -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 Routine training 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