When we talk about “Never Events” in medicine, we are referring to a list of errors or adverse events that should never happen to a patient while in the care of a hospital or physician. Some examples are wrong site surgery, mismatched blood transfusion, or hospital acquired pressure ulcers. The Centers for Medicare and Medicaid Services (CMS) defines Never Events as “serious, preventable and costly medical errors”. Never Events and “Serious Reportable Events” share the same meaning and can be used interchangeably in the medical environment to describe incidents that are considered to be unacceptable. Nurses play a very important role in the prevention of Never Events through risk anticipation and evidence based practice. Organizations have adopted safety guidelines in order …show more content…
In addition, the hospital must investigate the event and contact The Joint Commission (TJC) or state agency. Along with Never Events, other events occur in health care can result in a negative patient experience. Reporting of Hospital Acquired Conditions (HACs), which are conditions or complications that develop during a hospital stay that are not present upon admission, and Present on Admission (POAs), defined as conditions that are present upon admission, are new plans which were developed as a result of the National Quality Forum’s study. Since 2008, under the Deficit Reduction Act of 2005, hospitals do not receive payment for cases in which certain conditions occur during hospitalization that were not present upon the patient’s admission (Miller, 2011). The Centers for Medicare and Medicaid denies reimbursement for these as they may or may not include Never Events and are considered to be “hospital