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Volumn 41, Issue 6, 2015, Pages 279-288

"Never events" and the quest to reduce preventable harm

Author keywords

[No Author keywords available]

Indexed keywords

DOCUMENTATION; GOVERNMENT; HOSPITAL MANAGEMENT; HUMAN; MEDICAL ERROR; MEDICATION ERROR; PATIENT SAFETY; PREVENTION AND CONTROL; UNITED STATES;

EID: 84974817823     PISSN: 15537250     EISSN: None     Source Type: Journal    
DOI: 10.1016/S1553-7250(15)41038-4     Document Type: Article
Times cited : (30)

References (44)
  • 1
    • 58849122821 scopus 로고    scopus 로고
    • Centers for Medicare and Medicaid Services' "never events": An analysis and recommendations to hospitals
    • Mattie AS, Webster BL. Centers for Medicare and Medicaid Services' "never events": an analysis and recommendations to hospitals. Health Care Manag (Frederick) 2008;27(4):338-349.
    • (2008) Health Care Manag (Frederick) , vol.27 , Issue.4 , pp. 338-349
    • Mattie, A.S.1    Webster, B.L.2
  • 2
    • 77949471972 scopus 로고    scopus 로고
    • Serious reportable adverse events in health care
    • Henriksen K, et al., editors: Programs, Tools, and Products. Rockville, MD: Agency for Healthcare Research and Quality, Accessed Apr 22, 2015
    • Kizer KW, Stegun MB. Serious reportable adverse events in health care. In Henriksen K, et al., editors: Advances in Patient Safety: From Research to Implementation, vol. 4: Programs, Tools, and Products. Rockville, MD: Agency for Healthcare Research and Quality, 2005, 339-352. Accessed Apr 22, 2015. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf.
    • (2005) Advances in Patient Safety: From Research to Implementation , vol.4 , pp. 339-352
    • Kizer, K.W.1    Stegun, M.B.2
  • 6
  • 7
    • 79960517063 scopus 로고    scopus 로고
    • Updated: Dec Accessed Apr 22, 2014
    • Agency for Health Care Quality and Research. Patient Safety Primer: Never Events. 2012 (Updated: Dec 2014.) Accessed Apr 22, 2014. http://psnet.ahrq.gov/primer.aspx?primerID=3.
    • (2012) Patient Safety Primer: Never Events
  • 8
    • 78650029400 scopus 로고    scopus 로고
    • Comparing gains and losses
    • McGraw AP, et al. Comparing gains and losses. Psychol Sci. 2010;21(10):1438-1445.
    • (2010) Psychol Sci. , vol.21 , Issue.10 , pp. 1438-1445
    • McGraw, A.P.1
  • 9
    • 66649092621 scopus 로고    scopus 로고
    • Ending extra payment for "never events" - Stronger incentives for patients' safety
    • Jun 4
    • Milstein A. Ending extra payment for "never events" - Stronger incentives for patients' safety. N Engl J Med. 2009 Jun 4;360(23):2388-2390.
    • (2009) N Engl J Med. , vol.360 , Issue.23 , pp. 2388-2390
    • Milstein, A.1
  • 10
    • 84970977742 scopus 로고    scopus 로고
    • Clarifying "never events" and introducing "always events."
    • Dec 31
    • Lembitz A, Clarke TJ. Clarifying "never events" and introducing "always events." Patient Saf Surg. 2009 Dec 31;3:26.
    • (2009) Patient Saf Surg. , vol.3 , pp. 26
    • Lembitz, A.1    Clarke, T.J.2
  • 11
    • 85185367269 scopus 로고    scopus 로고
    • Updated: Apr 1, Accessed Apr 22, 2015
    • The Leapfrog Group. Fact Sheet: Never Events. (Updated: Apr 1, 2014.) Accessed Apr 22, 2015. https://leapfroghospitalsurvey.org/web/wp-content/uploads/neverevents.pdf.
    • (2014) Fact Sheet: Never Events
  • 12
    • 70149110684 scopus 로고    scopus 로고
    • Never events": Not every hospital-acquired infection is preventable
    • Sep 1
    • Brown J, Doloresco Iii F, Mylotte JM. "Never events": Not every hospital-acquired infection is preventable. Clin Infect Dis. 2009 Sep 1;49(5):743-746.
    • (2009) Clin Infect Dis. , vol.49 , Issue.5 , pp. 743-746
    • Brown, J.1    Doloresco, F.2    Mylotte, J.M.3
  • 13
    • 84908164996 scopus 로고    scopus 로고
    • Update. Dec 12, 2013. Accessed Apr 22, 2015
    • NHS England, Patient Safety Domain Team. The Never Events List; 2013/14 Update. Dec 12, 2013. Accessed Apr 22, 2015. http://www.england.nhs.uk/wp-content/uploads/2013/12/nev-ev-list-1314-clar.pdf.
    • (2013) The Never Events List
  • 14
    • 78651254445 scopus 로고    scopus 로고
    • OEI-06-09-00090. Washington, DC: US Department of Health & Human Services, Office of Inspector General, Accessed Apr 22, 2015
    • Golladay KK, et al. Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. OEI-06-09-00090. Washington, DC: US Department of Health & Human Services, Office of Inspector General, 2010. Accessed Apr 22, 2015. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.
    • (2010) Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries
    • Golladay, K.K.1
  • 15
    • 85185357771 scopus 로고    scopus 로고
    • Accessed Apr 22, 2015
    • The Joint Commission. Patient Safety Systems (PS). 2015. Accessed Apr 22, 2015. http://www.jointcommission.org/assets/1/6/PSC-for-Web.pdf.
    • (2015) Patient Safety Systems (PS)
  • 16
    • 84975820806 scopus 로고    scopus 로고
    • Accessed Apr 22, 2015
    • The Joint Commission. Sentinel Events (SE). 2015. Accessed Apr 22, 2015. http://www.jointcommission.org/assets/1/6/CAMH-24-SE-all-CURRENT.pdf.
    • (2015) Sentinel Events (SE)
  • 20
    • 77957987000 scopus 로고    scopus 로고
    • Updated: Aug 27, Accessed Apr 22, 2015
    • Centers for Medicare & Medicaid Services. Hospital-Acquired Conditions. (Updated: Aug 27, 2014.) Accessed Apr 22, 2015. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired-Conditions.html.
    • (2014) Hospital-Acquired Conditions
  • 21
    • 43549086432 scopus 로고    scopus 로고
    • The wisdom and justice of not paying for "preventable complications."
    • May 14
    • Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for "preventable complications." JAMA. 2008 May 14;299(18):2197-2199.
    • (2008) JAMA , vol.299 , Issue.18 , pp. 2197-2199
    • Pronovost, P.J.1    Goeschel, C.A.2    Wachter, R.M.3
  • 22
    • 84862897326 scopus 로고    scopus 로고
    • Limitations of administrative databases
    • Jun 27; author reply 2589-90
    • Haut ER, Pronovost PJ, Schneider EB. Limitations of administrative databases. JAMA, 2012 Jun 27;307(24):2589; author reply 2589-90.
    • (2012) JAMA , vol.307 , Issue.24 , pp. 2589
    • Haut, E.R.1    Pronovost, P.J.2    Schneider, E.B.3
  • 23
    • 84970987307 scopus 로고    scopus 로고
    • Medicaid to Stop Paying for Hospital Mistakes
    • Jun 1, Accessed Apr 22, 2015
    • Kaiser Health News. Medicaid to Stop Paying for Hospital Mistakes. Galewitz P. Jun 1, 2011. Accessed Apr 22, 2015. http://www.kaiserhealthnews.org/stories/2011/june/01/medicaid-hospital-medical-error-payment-short-take.aspx.
    • (2011) Kaiser Health News
    • Galewitz, P.1
  • 24
    • 85185366413 scopus 로고    scopus 로고
    • CMS Releases Hospital Error, Injury Data
    • Apr 8, Accessed Apr 22, 2015
    • MedPage Today. CMS Releases Hospital Error, Injury Data. Walker EP. Apr 8, 2011. Accessed Apr 22, 2015. http://www.medpagetoday.com/PublicHealthPolicy/Medicare/25816.
    • (2011) MedPage Today
    • Walker, E.P.1
  • 25
    • 85185359878 scopus 로고    scopus 로고
    • May 3, Accessed Apr 22, 2015
    • Advisory Board Company. CMS to Remove Never Events Data from Hospital Compare. May 3, 2013. Accessed Apr 22, 2015. http://www.advisory.com/daily-briefing/2013/05/03/cms-to-remove-never-events-datafrom-hospital-compare.
    • (2013) CMS to Remove Never Events Data from Hospital Compare
  • 26
    • 85185356574 scopus 로고    scopus 로고
    • Feds Reverse Course, Will Release Hospital Mistake Data
    • Sep 7, Accessed Apr 22, 2015
    • USA Today, Feds Reverse Course, Will Release Hospital Mistake Data. O'Donnell J. Sep 7, 2014. Accessed Apr 22, 2015. http://www.usatoday.com/story/news/nation/2014/09/07/hhs-change-reporting-hospital-mistakes-foreignobjects/15084175/.
    • (2014) USA Today
    • O'Donnell, J.1
  • 27
    • 79960064801 scopus 로고    scopus 로고
    • A review of the Office of Inspector General's reports on adverse event identification and reporting
    • Howe CL. A review of the Office of Inspector General's reports on adverse event identification and reporting. J Healthc Risk Manag. 2011;30(4):48-54.
    • (2011) J Healthc Risk Manag , vol.30 , Issue.4 , pp. 48-54
    • Howe, C.L.1
  • 28
    • 85185358823 scopus 로고    scopus 로고
    • Individual hospital data on "never events"
    • to be published every quarter. Dec 13
    • Kmietowicz Z. Individual hospital data on "never events" to be published every quarter. BMJ. 2013 Dec 13;347:f7479.
    • (2013) BMJ , vol.347
    • Kmietowicz, Z.1
  • 29
    • 84875221482 scopus 로고    scopus 로고
    • Surgical never events in the United States
    • Mehtsun WT, et al. Surgical never events in the United States. Surgery. 2013;153(4):465-472.
    • (2013) Surgery , vol.153 , Issue.4 , pp. 465-472
    • Mehtsun, W.T.1
  • 31
    • 84974817180 scopus 로고    scopus 로고
    • Dec 12, Accessed Apr 22, 2015
    • NHS England, Patient Safety Domain Team. Never Events Data Summary for 2012/13. Dec 12, 2013. Accessed Apr 22, 2015. http://www.england.nhs.uk/wp-content/uploads/2013/12/nev-ev-data-sum-1213.pdf.
    • (2013) Never Events Data Summary for 2012/13
  • 32
    • 65249180158 scopus 로고    scopus 로고
    • Targeting "never events."
    • Rosenthal K. Targeting "never events." Nurs Manage. 2008;39(12):35-38.
    • (2008) Nurs Manage , vol.39 , Issue.12 , pp. 35-38
    • Rosenthal, K.1
  • 33
    • 84873187987 scopus 로고    scopus 로고
    • Avoiding never events: Improving nasogastric intubation practice and standards
    • Law RL, et al. Avoiding never events: Improving nasogastric intubation practice and standards. Clin Radiol. 2013;68(3):239-244.
    • (2013) Clin Radiol. , vol.68 , Issue.3 , pp. 239-244
    • Law, R.L.1
  • 34
    • 84870424305 scopus 로고    scopus 로고
    • Accessed Apr 22, 2015
    • The Joint Commission. Patient Safety.Accessed Apr 22, 2015. http://www.jointcommission.org/topics/patient-safety.aspx
    • Patient Safety
  • 35
    • 28844491799 scopus 로고    scopus 로고
    • Health care provider use of private sector internal error-reporting systems
    • Roumm AR, Sciamanna CN, Nash DB. Health care provider use of private sector internal error-reporting systems. Am J Med Qual. 2005;20(6):304-312.
    • (2005) Am J Med Qual. , vol.20 , Issue.6 , pp. 304-312
    • Roumm, A.R.1    Sciamanna, C.N.2    Nash, D.B.3
  • 36
    • 18644383685 scopus 로고    scopus 로고
    • Five years after To Err Is Human: What have we learned?
    • May 18
    • Leape LL, Berwick DM. Five years after To Err Is Human: What have we learned? JAMA. 2005May 18;293(19):2384-2390.
    • (2005) JAMA , vol.293 , Issue.19 , pp. 2384-2390
    • Leape, L.L.1    Berwick, D.M.2
  • 37
    • 79958723416 scopus 로고    scopus 로고
    • Surveillance bias in outcomes reporting
    • Jun 15
    • Haut ER, Pronovost PJ. Surveillance bias in outcomes reporting. JAMA. 2011 Jun 15;305(23):2462-2463.
    • (2011) JAMA , vol.305 , Issue.23 , pp. 2462-2463
    • Haut, E.R.1    Pronovost, P.J.2
  • 38
    • 85185364789 scopus 로고    scopus 로고
    • Measuring adverse events in hospitalized patients: An administrative method for measuring harm
    • Epub Apr 8
    • Martin J, et al. Measuring adverse events in hospitalized patients: An administrative method for measuring harm. J Patient Saf. Epub 2014 Apr 8.
    • (2014) J Patient Saf
    • Martin, J.1
  • 39
    • 84906858395 scopus 로고    scopus 로고
    • Young and reckless? Greater standardization and transparency of performance is needed for pediatric performance measures
    • Austin JM, Miller MR, Pronovost PJ. Young and reckless? Greater standardization and transparency of performance is needed for pediatric performance measures. Acad Pediatr 2014;14(5 Suppl):S15-16.
    • (2014) Acad Pediatr , vol.14 , Issue.5 , pp. S15-S16
    • Austin, J.M.1    Miller, M.R.2    Pronovost, P.J.3
  • 40
    • 84974799874 scopus 로고    scopus 로고
    • Ensuring the integrity and transparency of public reports: How a possible oversight model could benefit healthcare
    • Austin JM, Young GJ, Pronovost PJ. Ensuring the integrity and transparency of public reports: How a possible oversight model could benefit healthcare. American Journal of Accountable Care. 2014;2(4):13-14.
    • (2014) American Journal of Accountable Care , vol.2 , Issue.4 , pp. 13-14
    • Austin, J.M.1    Young, G.J.2    Pronovost, P.J.3
  • 42
    • 79959270534 scopus 로고    scopus 로고
    • Explaining Michigan: Developing an ex post theory of a quality improvement program
    • Dixon-Woods M, et al. Explaining Michigan: Developing an ex post theory of a quality improvement program. Milbank Q. 2011;89(2):167-205.
    • (2011) Milbank Q , vol.89 , Issue.2 , pp. 167-205
    • Dixon-Woods, M.1
  • 43
    • 84883032902 scopus 로고    scopus 로고
    • Accessed Apr 20, 2015
    • Centers for Medicare & Medicaid Services. Partnership for Patients.Accessed Apr 20, 2015. http://innovation.cms.gov/initiatives/partnership-for-patients/.
    • Partnership for Patients
  • 44
    • 84907377121 scopus 로고    scopus 로고
    • Did hospital engagement networks actually improve care?
    • Aug 21
    • Pronovost P, Jha AK. Did hospital engagement networks actually improve care? N Engl J Med. 2014 Aug 21;371(8):691-693.
    • (2014) N Engl J Med. , vol.371 , Issue.8 , pp. 691-693
    • Pronovost, P.1    Jha, A.K.2


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.