Healthcare News & Insights

Make zero ‘never events’ your hospital’s goal

“Never events” received their name because they’re serious adverse events that should never happen – they’re 100% preventable. Problem is, they do happen and with alarming frequency. And despite mandatory reporting, only about half the states comply, and what they report varies due to flawed measurement processes. So how can hospitals improve?


Take a page from the Mayo Clinic’s book.

To move to the next level of patient safety, a few years ago the facility implemented a mortality-review process. Instead of only looking at never events, all aspects of care delivered to every patient who dies at the facility are examined, Dr. Timothy Morgenthaler, chief patient safety officer, and Dr. Charles Harper, executive dean for practice at the Mayo Clinic, explained in Harvard Business Review.

“We look for trends in opportunities in order to prioritize improvement work across our hospitals,” wrote the doctors. “Toward that end we produce metrics on a quarterly basis concerning how frequently we saw care issues or improvement opportunities. In addition, we display a Pareto chart to graphically depict the most prevalent opportunities for improvement. We use these measures [to] help us focus our improvement efforts.”

Better process

One procedure that was targeted for improvement through this method was smooth and safe direct admissions and transfers into the facility. Sometimes patients who were very ill were admitted to areas of the facility that weren’t prepared to take care them. This would then cause patients to be transferred to a department with a higher level of care.

After pinpointing the problem – insufficient information – a better process was created so patients would arrive in the appropriate area and receive the care they needed immediately. This new standard of care was then added to the “Mayo Clinic Patient Safety Essentials,” which are followed by each facility in the system.

Some of the changes are easy to make, while others require a team of experts. But no matter the change, once it’s made, everyone in the system is required to follow the new protocol.

Then when an incident associated with serious harm is reported or found, it’s looked at to see if the standards of care were followed. If they weren’t, it’s deemed a “preventable harm” event, and the board of trustees focuses on their frequency.

When the mortality-review process was first implemented executives would find care issues that needed improvement about 23% of the time. At the time of the report, the number dropped to around 13% – a sign that progress is definitely being made when it comes to patient safety.

Technological help

Additional improvement opportunities are always being looked for since the ultimate goal is to have zero never events.

So the facility incorporated technology into the mix to help fix patient care areas that need improvement and are hindered at times by human limitations.

One such area was medications.

To ensure all patients are taking the proper dose of their specific medication at the correct time, all Mayo Clinic hospitals:

  • Have their clinicians enter all prescriptions via a computerized menu directly into an information system that automatically checks for errors – no handwritten prescriptions are allowed
  • Use an advanced pharmacy-preparation and packaging system that attaches a bar code to each medication with patient-specific info and dosing instructions, and
  • Have the person dispensing the medicine use a bar-code reader that compares the patient’s code with the medicine’s code.

Always room for improvement

While many improvements have been made, a few areas are still challenging:

  • pressure ulcer
  • wrong body site procedure
  • wrong procedure, and
  • patient falls that result in injuries.

Continued progress will require new investments in tools, care environment and caregivers, which take time and money.

To get patient falls that result in injuries – a costly problem – down to zero events could require redesign of hospital rooms (larger, private rooms with built-in and efficient patient-lift devices, bathrooms that accommodate ambulatory-assist devices and contrasting colors to help the elderly see).

And still other issues, like surgical and procedural events, are largely due to communication problems.

While new technological developments can help these issues, until they’re created, clinicians may have to slow down and do less. Not a popular option since clinicians are being asked to do more with less and still get great statistics, but one that is definitely needed.

Reason: The doctors studied 60 surgical near misses and safety events, and found the root cause for many of them was cognitive factors such as channeled attention on a single issue, overconfidence, inadequate vigilance and distractions.




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