Never Event Frequency 'Troubling,' Standards Lacking

Mandatory state reporting of adverse medical errors is lagging and changes are needed in the way hospitals and health systems define and analyze so-called "never events," researchers say.

Changes are needed in the way the health system defines, collects information about, and analyzes so-called "never events," according to Johns Hopkins patient safety experts writing in The Joint Commission Journal on Quality and Patient Safety .

Never events are serious adverse events that, as the name says, should "never" happen. But efforts to identify, report, and prevent them have been uneven.  

And they are occurring "with a troubling frequency," the authors write. They also note that "Lapses in patient safety are a major quality problem in health care, causing more than 200,000 deaths, 2.4 billion extra hospital days, and between $17 billion and $29 billion in excess hospital costs in the United States each year."

In addition, the Centers for Medicare & Medicaid Services "does not pay hospitals a higher reimbursement for certain" healthcare-acquired conditions that result from never events.

Variable Event Reporting
Although the Institute of Medicine called for mandatory state reporting of adverse medical errors more than a decade ago in its landmark To Err Is Human report, only 26 states and the District of Columbia are doing so, and the extent of what they actually report varies.

Georgia, for example, requires hospitals to report adverse events, but doesn't require them to publicly report individual hospital data. It also doesn't report aggregated data.

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"Public reporting plays an important role, and really speaks to accountability," says the study's lead author, J. Matthew Austin, PhD, assistant professor in the Johns Hopkins Armstrong Institute for Patient Safety and Quality and in the Johns Hopkins University School of Medicine Department of Anesthesiology and Critical Care Medicine.

Another problem is the definition of term itself, on which there is no universal agreement.

What is a Never Event?
"One of the challenges we have with never events is that different organizations have adopted different definitions of what constitutes a never event," Austin says. For instance, there's disagreement about whether never events should include adverse events that are entirely avoidable, or ones that are mostly avoidable.

There's also no standard list of adverse events that qualify for never event status. For instance, the paper says that the National Quality Forum defines wrong site surgery as a never event, whereas CMS does not. CMS does, however, define any catheter-associated urinary tract infection as a never event, while the National Quality Forum does not, the paper says.

And then there are what The Joint Commission calls sentinel events, which "signal the need for immediate investigation and response."

J. Matthew Austin Assistant Professor Johns Hopkins University

In light of these nuances and discrepancies, the resulting disjointed reporting, and the rate that never-events occur, the authors offer several recommendations.

They call first for establishing standard definitions and measures for never events, as well as a standard set of adverse events that would be defined as never events, such as the one developed by the National Quality Forum.

"It is shocking," that there isn't a standard definition already, Austin says.

Increased transparency is also needed.

"We hold up the state of Minnesota… as [having] a format that we think other states should aspire to… They report out their events by facility and they report out what the impact was to patient," Austin says. Hospitals in Minnesota must report when one of 29 adverse events occurs, and the state's department of health issues an annual report about adverse health events. Last year it released a 10-year longitudinal review of its data.  

Austin also says healthcare leaders, policymakers, providers, and other stakeholders should find better ways to work together to focus on quality improvement efforts.

And there's a role for individual hospitals to play, too.

Each hospital can work to understand what events it's had, conduct analyses of those events, and ensure that systems are in place or get adjusted to prevent such events from occurring again. "All of that happens at a very local level," he says.

Local collaboration should also be encouraged, Austin says. Although hospitals are often operating in a competitive environment, there still needs to be knowledge and information sharing across institutions. Austin says hospitals can share finding with others to incorporate learning into different organizations and prevent events for all patients.

"It's really this idea of local implementation, but more global sharing," Austin says. "Sharing information is a key component to seeing improvements and success. That's the willingness to share with friends, and perhaps competitors, what issues their own hospital has experienced and a global effort to reduce patient harm."