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The List Of ‘Never Events’ Grows

iStock_000006640216XSmallEffective 10/1/2008, hospitals and nursing homes will no longer be able to seek reimbursement from Medicare for medical conditions deemed preventable.  The Centers for Medicare & Medicaid Services is asking states to coordinate Medicare and Medicaid policies to prevent facilities from billing Medicaid for preventable medical errors for individuals who may be eligible for both Medicare and Medicaid.  Most nursing home residents are eligible for both Medicare and Medicaid.

The ‘never events’ is a listing of 28 categorized errors that CMS has determined to be clearly preventable.  CMS estimates that errors on the ‘never list’ account for $4.5 billion in annual Medicare charges.  The list is a step toward holding bad medical facilities accountable for the actions or neglect of their staff.  Without a never list, nursing homes and hospitals stand to actually benefit financially from rendering poor care.  Theoretically, a nursing home resident could develop a stage 4 pressure sore due poor care and the facility could submit months of wound care treatment (and bills) to Medicare for payment.  By category, here is the list of ‘never events’:

Surgical Events

  • Surgery on wrong body part
  • Surgery on wrong patient
  • Wrong surgery on patient
  • Foreign object left in patient after surgery
  • Post-operative death in normal health patient
  • Implementation 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 intramuscular air embolism

Patient Protection Errors

  • 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
  • Maternal death / disability with low risk delivery
  • Death / disability associated with hypoglycemia
  • Death / disability associated with hyperbilirubinemia in neonates
  • State 3 or 4 pressure ulcers after admission
  • Death / disability due to spinal manipulative therapy

Environment Events

  • Death / disability associated with electric shock
  • Incident due to wrong oxygen or gas
  • Death / disability associated with a burn incurred within facility
  • Death / disability associated with a fall within facility
  • Death / disability associated with use of restraints within facility

Criminal Events

  • Impersonating a health care provider (i.e., physician, nurse)
  • Abduction of patient
  • Sexual assault of a patient within or on facility grounds

Clearly, the implementation of the ‘never list’ is a step towards better patient care.

Read McKnight’s article on CMS’s coordination of the ‘never list’ for Medicare and Medicaid here.
Look at CMS’s letter to State Medicaid and Medicare directors concerning ‘never events’ here.

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