Never Events: Cost, Impact, and the Value of Clinical Staff in Prevention – Robin Gilbert

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“Never events” is a term coined by Ken Keizer, MD, former CEO of National Quality Forum, in 2001, in reference to shocking medical errors that should never occur. Never events are devastating and costly for organizations. There are currently 29 events that are recognized as “never events”. Clinical nurses are highly competent with skills and knowledge that can reduce these events.

Quality starts at the bedside. Do you know the meaning and identification of never events? Have you participated in a root cause analysis? Do you understand what disclosure of the error means, or are these terms foreign to you?

This presentation will cover current requirements from National Quality Forum. You will learn the impact of “Never Events”, and how to become engaged in preventing events and making quality a goal of every team member on your staff.

OBJECTIVES

• Define and discuss the difference between “never events” and “sentinel events”.
• Discuss how to plan a root cause analysis and how to do a proper disclosure of the error.
• Discuss measures being used by clinical staff that assist in prevent “never events”.
• Identify potential causes of “never events” and developing a plan to prevent these causes.