NEVER EVENTS THAT ARE CAUSED ONLY BY CARELESSNESS
On July 31, 2008, the Centers for Medicare & Medicaid Services (CMS) announced new Medicare and Medicaid payment and coverage policies to improve safety for hospitalized patients. The list of events below are “NEVER EVENTS”.
- Foreign Object Retained After Surgery
- Air Embolism
- Blood Incompatibility
- Pressure Ulcer Stages III & IV
- Falls and Trauma:
- Fracture
- Dislocation
- Intracranial Injury
- Crushing Injury
- Burn
- Electric Shock
- Catheter-Associated Urinary Tract Infection (UTI)
- Vascular Catheter-Associated Infection
- Manifestations of Poor Glycemic Control
The following events if they occur are considered Serious Reportable Adverse Events:
|
Current NQF Serious Reportable Adverse Events |
CMS VBP Efforts |
|
Surgical Events | |
|
Surgery on wrong body part |
National Coverage Determination |
|
Surgery on wrong patient |
National Coverage Determination |
|
Wrong surgery on a patient |
National Coverage Determination |
|
Foreign object left in patient after surgery |
Hospital-Acquired Condition |
|
Post-operative death in normal health patient | |
|
Implantation of wrong egg | |
|
Product or Device Events | |
|
Death/disability associated with use of contaminated drugs | |
|
Death/disability associated with use of device other than as intended | |
|
Death/disability associated with intravascular air embolism |
Hospital-Acquired Condition |
|
Patient Protection Events | |
|
Infant discharged to wrong person | |
|
Death/disability due to patient elopement | |
|
Patient suicide or attempted suicide resulting in disability | |
|
Care Management Events | |
|
Death/disability associated with medication error | |
|
Death/disability associated with incompatible blood |
Hospital-Acquired Condition |
|
Maternal death/disability with low risk delivery | |
|
Death/disability associated with hypoglycemia |
Hospital-Acquired Condition |
|
Death/disability associated with hyperbilirubinemia in neonates | |
|
Stage 3 or 4 pressure ulcers after admission |
Hospital-Acquired Condition |
|
Death/disability due to spinal manipulative therapy | |
|
Environment Events | |
|
Death/disability associated with electric shock |
Hospital-Acquired Condition |
|
Incident due to wrong oxygen or other gas | |
|
Death/disability associated with a burn incurred within facility |
Hospital-Acquired Condition |
|
Death/disability associated with a fall within facility |
Hospital-Acquired Condition |
|
Death/disability associated with use of restraints within facility |
For more information, see: www.cms.hhs.gov/AcuteInpatientPPS/
