Never Events and Serious Reportable Events
The terms "never events" and "serious reportable events" (SREs) are used frequently in patient safety discussions, and CPHQ candidates must understand their definitions, categories, and implications for healthcare quality and reimbursement.
Origin of "Never Events"
The term "never event" was introduced by Ken Kizer in 2001 to describe particularly shocking medical errors that should never occur. The original list included events such as wrong-site surgery and infant discharge to the wrong person. The National Quality Forum (NQF) adopted and expanded this concept into its list of Serious Reportable Events, first published in 2002 and updated periodically.
NQF Serious Reportable Events Categories
The NQF organizes SREs into several categories. Surgical or invasive procedure events include wrong site, wrong patient, wrong procedure, and retained foreign objects. Product or device events include contaminated drugs or devices and use of devices other than as intended. Patient protection events include patient elopement and suicide in a 24-hour care setting. Care management events include medication errors leading to death, stage 3 or 4 pressure injuries acquired after admission, and patient death associated with falls. Environmental events include electric shock and wrong gas delivery. Radiologic events and criminal events round out the categories.
Payment Implications
The Centers for Medicare and Medicaid Services (CMS) adopted a policy in 2008 to stop paying for additional costs associated with certain preventable conditions (hospital-acquired conditions, or HACs). While the CMS HAC list is not identical to the NQF SRE list, there is significant overlap. Many private payers have adopted similar non-payment policies. This financial consequence has increased organizational focus on preventing these events and has raised awareness of the importance of accurate clinical documentation.
Reporting Requirements
Many states have enacted mandatory reporting laws for SREs. The specific events that must be reported vary by state, and quality professionals need to know their state's requirements. Reporting typically goes to the state health department or a designated patient safety organization. Some states make aggregate data publicly available, creating transparency and additional incentive for prevention.
Prevention Strategies
Organizations should maintain a comprehensive list of NQF SREs, ensure all staff understand which events qualify, have robust reporting mechanisms in place, conduct thorough investigations when events occur, and implement evidence-based prevention strategies. Quality professionals play a central role in tracking these events, analyzing trends, and driving prevention efforts. For the CPHQ exam, be prepared to identify which events qualify as SREs and understand the relationship between SREs, HACs, and non-payment policies.