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The adage “never say never” has taken on new meaning as it is now being associated with hospital errors. The movement to align patient safety and payment has arrived. This emerging ethical and patient safety imperative is that hospitals should not be reimbursed for medical errors that should never happen.

In 2002, the National Quality Forum (NQF) published a report, “Serious Reportable Events in Healthcare,” which identified 27 adverse events that are serious, largely preventable, and of concern to both the public and health care providers.¹ The NQF is a voluntary consensus standard-setting organization. This organization formally launched a project and report that established consensus among consumers, providers, purchasers, researchers, and other health care stakeholders about preventable adverse events that should never occur and defined them in a way that should they occur, it would be clear what had to be reported. According to the NQF, “never events” are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and indicate a real problem in the safety and credibility of a health care facility.²

In November 2007, BlueCross BlueShield Association announced that it also planned to end payments for never events. Since then, many hospitals have stepped forward on this issue. Nationally, approximately 1300 hospitals have pledged to waive all costs directly associated with never events.³ This focus on never events follows the new Centers for Medicare and Medicaid Services rule, which took effect in October of 2008. The rule denies payment for eight hospital-acquired conditions. Five of the eight—pressure ulcers, air embolism, blood incompatibility, object left in patient after surgery, and patient falls—are also NQF endorsed never events. It is widely expected that even more private payers will follow Medicare's lead in this area. Philosophically, payments for never events are not consistent with the goals of reimbursement for quality and efficiency of care. By reducing or eliminating payments for “never events,” the hope is that more resources can be directed toward preventing these events rather than paying more when they occur.

We are certainly experiencing an accountability epidemic in health care. The public is holding health care organizations to be accountable for patient outcomes. As health care providers, it is vital for us to say we are willing to be accountable and not charge for mistakes. However, the challenge for us is that some never events, such as pressure ulcers and patient falls, can be associated with multiple variables, unintended consequences, and challenges.

Patient safety is certainly a major national initiative. During the past few years the emphasis has been to improve poor systems that lead to errors, thus promoting a culture of safety versus a culture of blame. This reality increases the need for sound, evidence-based practice, and resources on patient safety. Health care providers, including nurses, can easily become overwhelmed with the amount of information available on patient safety issues. Patients are being asked to assume more responsibility for their own safety by asking questions and seeking out more information. As nurses we need to be cognizant of where to locate patient safety information and how to advocate for patient safety through various stakeholders. It is imperative that as nurses we have resources available and are able to seek out those resources and share our findings with other health care providers, and use the information to improve the quality of our care. We need to embody the culture of safety. We should identify and implement best practices in our work environments and nursing care. It is imperative that we ensure the assessment, implementation, and documentation of our patients' needs and individualized plans of care. We need to develop thorough communication processes for continuity of care and promotion of patient safety. We also must be informed and take an active role in reporting never events within our own institutions. Inquire within your institution about what safety issues are being monitored internally. Take an active role in understanding your facility's patient safety goals and developing your units' safety goals. Each one of us has an important role to play in fostering and ensuring a culture of patient safety. Each one of us has a role in the dissemination of our findings and knowledge. Share with us your best practice initiatives, protocols, and plans of care. Share with us your outcomes. We look forward to hearing from you! Never say never.

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References 

1. National Quality Forum . Serious reportable events in healthcare: a consensus report. Washington, DC: National Quality Forum; 2002;
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2. National Quality Forum (2008). Washington, DC. Available at http://www.qualityforum.org. Accessed March 6, 2008.
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3. National Patient Safety Organization (2008). North Adams, Massachusetts. Available at http://www.npsf.org. Accessed March 6, 2008.
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