The term “never event” is commonly applied to pressure ulcers, giving the impression that they are always associated with medical error. As such, it lends this outcome an emotional charge that can lead to misplaced patient dissatisfaction and unnecessary accusations of wrongdoing or poor quality. Although pressure ulcers are sometimes associated with factors such as inadequate staffing and nutritional care, the preventability of all pressure ulcers has never been proven, and most caregivers agree that they can occur even in the best of circumstances. This post will review the history of the term “never event” in the context of pressure ulcers.
The focus on preventable medical errors began in 1999 with the landmark Institute of Medicine (IOM) report, To Err is Human: Building a Safer Healthcare System. This document underscored the high cost of medical errors that include adverse drug events, improper transfusions, surgical injuries, wrong-site surgery, restraint-related injuries, falls, and others. One conclusion was that most errors are caused not by individual recklessness or a particular group, but by faulty systems that lead people to make mistakes or fail to prevent them. This report did not incorporate the term “never event,” which was coined two years later.
According to the Agency for Healthcare Quality and Research (AHRQ), the term “never event” was introduced in 2001 by Ken Kizer MD, former CEO of the National Quality Forum (NQF) in reference to medical errors such as wrong-site surgery that should never occur. The NQF was created in 1999 by a coalition of public and private sector supporters to develop standards for measuring quality and efficiency of healthcare. In response to the IOM report, The Agency for Healthcare Policy and Research, later renamed AHRQ, contracted the NQF to produce a list of adverse outcomes to be employed in a mandatory quality reporting system.
Since introducing the term, the National Quality Forum has moved away from “never event” to describe outcomes that should not occur in healthcare settings, instead using “Serious Reportable Events,” or SREs. The NQF describes SREs as “largely preventable” errors and events that are of concern to the public and healthcare providers, that warrant careful investigation and should be targeted for mandatory public reporting. The National Quality Forum’s list of SREs includes stage 3 and 4 pressure ulcers that occur after admission to a healthcare facility.
In an effort to cut spending, Congress mandated the Centers for Medicare and Medicaid Services (CMS) to select diagnoses that have a high cost and/or high volume, result in a higher payment when present as a secondary diagnosis, and could reasonably be prevented through evidence-based guidelines. In 2008, CMS implemented policies that deny Medicare payment for treatment of specific hospital-acquired conditions (HACs). The list of HACs includes stage 3 and 4 pressure ulcers that occur after admission to a hospital, but the final rule does not use the term “never event.”
Despite the fact that neither CMS nor NQF use the term “never event,” the Leapfrog group has held onto the term. The Leapfrog Group is an independent, national not-for-profit organization that advocates quality healthcare, and publishes an annual hospital survey that assesses performance using quality measures that include stage 3 and 4 facility-acquired pressure ulcers. On their website they note that some SREs may not be preventable and acknowledge that the term “never event” may be unfair to providers. Nonetheless they cite severe adverse outcomes such as amputation of the wrong limb as justification to retain the term.
But is it fair to compare a stage 3 pressure ulcer to wrong-site surgery, or is this simply a rhetorical flourish to demonstrate a point? The avoidability of pressure ulcers has been debated since the time of Jean Martin Charcot in the 19th century, and the controversy continues to this day. Experts acknowledge that even with appropriate preventive interventions, there may be irreversible or unmodifiable comorbidities and risk factors that render pressure ulcers unavoidable.
This does not infer that the requirement for preventive measures should be abandoned. Instead, we need to continue vigilance regarding risk factor assessment and intervention, and increase funding for research to find better systems and technologies to prevent a larger percentage of ulcers while striving to heal the ones that already exist.
The term “never event,” although expressing an ideal, can sometimes be unjustified – casting a shadow of wrongdoing or lapse in quality when everything has been done correctly. Nonetheless the colloquial term “never event” as applied to pressure ulcers will likely remain with us, as it is catchy and makes a great sound bite. However until it is proven that pressure ulcer rates can truly reach zero, this term will hold caregivers to an unrealistic standard.
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Download NQF information on Serious Reportable Events (SREs)
Download the CMS Fact Sheet on Hospital Acquired Conditions (HACs)
Read the CMS final rule on HACs published in the Federal Register
Read the Leapfrog Group’s statement on Never Events
Historical Roots of the “Avoidable-Unavoidable” Pressure Ulcer Controversy
Determining the Avoidability of Pressure Ulcers
New Research Sheds Light on Hospital Acquired Pressure Ulcers
New Pocket Guide to Pressure Ulcers
CMS recognizes the Kennedy Terminal Ulcer in Long-term Care Hospitals