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Invited Critique
February 2010

Broadening Never Events: Is It a Plausible Road to Improved Patient Safety?Comment on

Author Affiliations

Author Affiliation: Emory University, Atlanta, Georgia.

Arch Surg. 2010;145(2):151-152. doi:10.1001/archsurg.2009.278

The Institute of Medicine's landmark article on patient safety provided a new lens through which medical errors are viewed.1 Consequently, improvements in patient safety have become paramount to improving patient outcomes. The CMS, in their desire to respond to the need for increased patient safety and reduction of costly complications, have introduced the concept of “never events.” Never events, according to the CMS, are “serious, preventable, and costly medical errors.”2 Never events come from the National Quality Forum list of serious reportable adverse events and, for the most part, would be considered by anyone, health care worker or not, to be avoidable, such as infant abduction and wrong-site surgery. State-mandated reporting and payment reductions for never events has been promoted by CMS to assure hospitals' active role in reduction of these medical errors. Despite this punitive approach in a time of rising health care costs, few surgeons would disagree with eliminating never events such as a wrong surgical procedure on the wrong side of the wrong patient. Indeed, it is every surgeon's nightmare to envision being involved in such an error. Therefore, never events have spawned valuable research into systemwide team approaches to finding solutions in a fashion not traditionally seen in surgery. For example, the implementation of preoperative surgical checklists has been found to significantly improve patient outcomes.3

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