Question

A very important aspect of healthcare administration is avoiding never events as these are termed. Give an example of a never event, and explain how you would respond to such an event taking place in your own healthcare facility. Also, as hospital CEO, how would you work to prevent never events in your organization moving forward?

Answer 1

According to the national quality forum, never events are errors in medical care that are clearly identifiable, Preventable,and serious in their consequences for patients and that indicate a real problem in the safety and credibility of a health care facility.never events examples of include surgery on the wrong body part; foreign body left in a patient after surgery; mismatched blood transfusion; major medication error; severe pressure ulcer acquired in the hospital; and preventable post operative deaths.

With the key motive to improve accountability and safety in health Care delivery,it is my humble observation that we have a long way to go in reducing preventable harm in hospitals and the health system in general.

A never event is the kind of mistake ( medical errors) that should never happen in the field of medical treatment.

The leapfrog group suggested for actions to be taken following a never event.

1 apologize to the patient

2 report the event

3 perform a root cause analysis

4 walve costs directly related to the event

Prevent never events

* Build a culture that encourages transparency, teamwork and accountability.

* provide education and competency programs for adverse event risk areas.

* Collaborate with referral sources to stress the importance of full and complete information during transfers.

* utilize a standard document or data elements when transferring residents to medical appointments and or other levels of care.

* engage residents and or caregivers

. Ask question about

. conditions/ treatments

. check medication allergies

. encourage caregivers to keep a list of

Medications

. include the plan of care

* review adapt or implement a systematic process on medication safety systems:

. refer to adverse event tools

* consider the role of the pharmacist.

* consider the process around verbal orders.