Never Events, Hospital Acquired Conditions

Never Events: A severe event (pressure ulcer). The picture on the right shows a Stage IV Pressure Ulcer which is down to fascia. The patient was in his early 60's and admitted to an acute care facility with Coagulase Positive Staphylococcus Aureus sepsis five days after a cardiac catheterization. The pressure ulcer was noted on the patient's coccyx almost two weeks after his hospital admission. The patient also developed a bowel infection with Clostridium Difficile. (Click on Picture to Enlarge)

Little has been done since the publication of the Institute of Medicine's report in 2000 which found that approximately 98,000 patients die each year from Hospital Acquired Conditions (HAC).¹

The CDC estimates that there are 1.7 million hospital acquired infections each year that cause nearly 100,000 deaths,^2,3 which costs our US healthcare system between 28 billion to 33 billion dollars each year.⁴ Each infection can produce an additional cost of hospitalization of between $32,000 and $38,656.^5,6 The average cost of each healthcare acquired infection was estimated by AHRQ to be $43,000.⁷

Cost of Health Errors Online Calculator from GE Heatlhcare - It is Sobering for Kentucky	Graphic Illustration on The Magnitude of Hospital Acquired Conditions. (Click on Picture to Enlarge)

A recent White Paper from the CDC (Centers for Disease Control), SHEA (Society for Healthcare Epidemiology of America), APIC (Association for Professionals in Infection Control and Epidemiology) , ASTHO (Association of State and Territorial Epidemiologists), CSTE (The Council of State and Territorial Epidemiologists), and the PIDS (Pediatric Infectious Disease Society) stated the following:⁸

“The number of people who are sickened or die and the financial impact from HAIs are unacceptable high.”

Report an Event to the Empowered Patient Coalition &
Consumers Union Safe Patient Project

Thomas R. Frieden, MD, MPH Director of the CDC "An important role of public health agencies is to define the unacceptable. This concept has particular relevance for healthcare-associated infections. Evidence indicates that, with focused efforts, these once formidable infections can be greatly reduced in number, leading to a new normal for healthcare-associated infections as rare, unacceptable events."⁹

Umscheid et al. has concludes in the journal of Infection Control and Hospital Epidemiology that most of these infections are preventable"

"As many as 65%-70% of cases of CABSI (Catheter Associated Bloodstream Infections) and CAUTI (Catheter Associated Urinary Tract Infection) and 55% of cases of VAP (Ventilator Associated Pneumonia) and SSI (Surgical Site Infections) may be preventable with current evidence-based strategies. CAUTI may be the most preventable HAI. CABSI has the highest number of preventable deaths, followed by VAP."¹³

How common are adverse events. Here is what a November 2010 OIG report has found.

"We found that about one in seven hospitalized Medicare beneficiaries (13.5 percent) experienced harm as a result of an adverse event during hospital stays."¹⁰

Physician reviewers determined that 44 percent of events were preventable, most commonly because of medical errors, substandard care, and inadequate patient monitoring.¹⁰

In a study published in the New England Journal of Medicine found that patient harm was common and that the number of incidents did not decrease over time. 2341 adult admissions in 10 randomly selected North Carolina hospitals were reviewed and there were 25 episodes of harm per 100 admissions with 18% unique patient admissions had incidents of "harm"¹¹

In 2011, a disturbing study of three major hospitals found that errors occurred in one in three patients and that 90% of these errors which not have been identified by standard tracking systems from the Agency for Healthcare Research and Quality.¹²

History: The term "Never Events" was introduced in 2001 at the National Quality Forum by Dr. Ken Kizer, in response to severe, largely preventable, hospital acquired conditions. The NQF initially defined 27 conditions which were revised and expanded to 28 in 2006. The term "Never Events" was also redefined as "Serious Reportable Events". Many consumer groups including The LeapFrog Group have opposed this change in terminology. See Leapfrog Group's Policy Statement

Below are a list of the 28 NQF Serious Reportable Conditions. Surprising to many consumers, they do not included hospital acquired infections. Medicare has a separate list of hospital acquired conditions which are slated for nonpayment. This list also contains serous reportable conditions along with several additional hospital acquired conditions.

	Medicare HAC	NQF Serious Reportable Events
Surgical Events		x
1) Surgery performed on the wrong body part		x
2) Surgery performed on the wrong patient		x
3) Wrong surgical procedure performed on patient		x
4) Unintended retention of a foreign object in a patient	x	x
5) Artificial insemination with the wrong sperm or donor egg		x
6) Intraoperative or immediately postoperative death in an American Society of Anesthesiologist Class I Patient		x
Product or Device Events
7) Patient death or disability associated with use of contaminated drugs, devices, or biologics provided by the healthcare facility		x
8) Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used for functions other than as intended		x
9) Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a health care facility	x	x
Patient Protective Events
10) Infant discharged to the wrong person		x
11) Patient death or serious disability associated with patient elopement (disappearance)		x
12) Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a health care facility		x
Case Management Events
13) Patient death or serious disability associated with a medication error (eg, errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)		x
14) Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA- incompatible blood or blood products	x	x
15) Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility		x
16) Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility	x	x
17) Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates		x
18) Stage 3 or 4 pressure ulcers acquired after admission to a health care facility	x	x
19) Patient death or serious disability due to spinal manipulative therapy		x
Environmental Events
20) Patient death or serious disability associated with an electric shock or electrical cardioversion while being cared for in a health care facility		x
21) Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong as or is contaminated by toxic substances		x
22) Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility		x
23) Patient death or serious disability associated with a fall while being cared for in a health care facility	x	x
24) Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility		x
Criminal Events
25) Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider		x
26) Abduction of a patient of any age		x
27) Sexual assault on a patient within or on the grounds of the health care facility		x
28) Death or significant injury of a patient or staff member resulting from a physical assault (ie, battery) that occurs within or on the grounds of the health care facility		x

Medicare HAC's Not Classified as Severe Reportable Events by NQF
1) Catheter-Associated Urinary Tract Infections	x
2) Vascular Catheter-Associated Infection	x
3) Manifestations of Poor Glycemic Control (Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma, Secondary Diabetes with Ketoacidosis, Secondary Diabetes with Hyperosmolarity)	x
4) Deep Vein Thrombosia/Pulmary Embolism in total knee replacement and hip replacement.	x
5) Surgical Site Infections in Coronary Artery Bypass Graft, Gastroenterostomy, Laparoscopic gastric restrictive surgery and certain orthopedic procedures (spine, neck, shoulder, elbow)	x

References:

To Err Is Human: Building a Safer Health System. Kohn LT, Corrigan JM, and Donaldson MS, Editors. Institute of Medicine. National Academy Press. Washington D.C. 2000. http://www.nap.edu/openbook.php?isbn=0309068371
Klevens et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports. March-April 2007. Volume 122. http://www.cdc.gov/ncidod/dhqp/pdf/hicpac/infections_deaths.pdf
CDC: Estimates of Healthcare-Associated Infections
http://www.cdc.gov/ncidod/dhqp/hai.html
Besser, RE. CDC’s Role in Preventing Healthcare Associated Infections http://appropriations.house.gov/Witness_testimony/LHHS/Richard_Besser_04_01_09.pdf
Infections Due to Medical Care in Oregon Hospitals, 2003-2005 Oregon Health Policy and Research. Nov 2006 http://www.oregon.gov/OHPPR/RSCH/docs/HAI111406.pdf
Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003 Oct 8;290(14):1868-74. http://www.ncbi.nlm.nih.gov/pubmed/14532315
Lucado J, Paez K, Andrews R and Steiner C. Adult Hosptiail Stays with Infections Due to Medical Care, 2007. Statistical Brief #94 Healthcare Cost and Utilization Project AHRQ Aug 2010 http://www.hcup-us.ahrq.gov/reports/statbriefs/sb94.pdf
Cardo D, Dennehy PH, Halverson P, Fishman N, Kohn M, Murphy CL, Whitley Rj, and the HAI Elimination White Paper Writing Group. Moving toward elimination of healthcare-associated infections: A call to action. Infect Control Hosp Epidemiol. 2010 Oct;31:S42–S44.
http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/RegulatoryIssues/
CDC/AJIC_Elimin.pdf
Frieden TR, Maximizing Infection Prevention in the Next Decade: Defining the Unacceptable. Infect Control Hosp Epidemiol. 2010 Oct;31:S1–S3.
http://www.journals.uchicago.edu/doi/full/10.1086/656002
Levinson, DR. Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Nov. 2010 OEI-06-09-00090 Download Report
Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010 Nov 25;363(22):2124-34.
http://www.nejm.org/doi/full/10.1056/NEJMsa1004404 http://www.ncbi.nlm.nih.gov/pubmed/21105794
Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A and James BC. ‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured. Health Affairs. April 2011 vol. 30 no. 4 581-589. http://content.healthaffairs.org/content/30/4/581.abstract
Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011 Feb;32(2):101-14. http://www.ncbi.nlm.nih.gov/pubmed/21460463