A recent report published by the editors at American Medical News used statistics from Minnesota to deliver a snapshot of serious reportable events that take place in hospital settings. It indicated that in 2012, 41% of these “never events” involved pressure ulcers. About 26% were surgical mistakes, such as retained objects and wrong-patient procedures, and 25% involved falls. The remainder included events such as serious drug errors.
Never events, which are defined as serious medical errors or adverse events that should never be experienced by a patient, have serious consequences. Not only can they cause substantial harm to a patient, but they can also cost an institution financially. The damage suffered to an institution’s reputation can sometimes be irreparable.
In 2002, the official list of never events was published by the National Quality Forum, and in 2005 laws were enacted in several states, such as Minnesota, that required hospitals to report incidents that involved any of the 28 serious reportable events found on the list. To prevent the occurrence of never events, hospitals around the nation have worked diligently to establish effective cultures of safety.
“A culture of safety refers to the manner in which an organization handles or responds to safety issues and errors, as well as the attitudes and perceptions that exist around safety throughout the organization,” explained the authors behind “Preventing never events: What frontline nurses need to know,” a 2011 report produced to examine never events and how to avoid them. “Simplified, the safety culture is how the organization behaves when no one is watching. A high culture of safety is critical for preventing or reducing errors and improving overall healthcare quality. High-reliability organizations (HROs) are those institutions known for establishing a high culture of safety.”
To learn how WoundRounds can provide the high-reliability principles that are exhibited by many HROs, feel free to reach out to us. We would be happy to talk about how WoundRounds can provide automatic reports that can minimize risk and liability.
