The term never event, first introduced in 2001 by Ken Kizer and the National Quality Forum, has been adopted by the US Center for Medicare and Medicaid Services (CMS) to describe preventable hospital-acquired conditions, such as catheter-associated urinary tract infections (CAUTI).1 Between 60% and 75% of CAUTIs are avoidable when appropriate preventive strategies are used.2,3 Guidelines were introduced in 2005 through the Surgical Care Improvement Project by the US Centers for Disease Control and Prevention in attempt to prevent CAUTIs. In 2008, CMS stopped reimbursing hospitals for treatment of CAUTI as part of what it now known as the Hospital-Acquired Condition Reduction Program, with the goal of making CAUTIs a never event.1 However, despite these guidelines and payment penalties, CAUTIs continue to occur and cause significant morbidity for patients. We describe the incidence of CAUTI in a large academic medical center and show that even with prevention guideline adherence, CAUTI cannot truly be a never event.
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Kuy S, Gupta R, Roy C, Awad S. Incidence of Catheter-Associated Urinary Tract Infections With Compliance With Preventive Guidelines. JAMA Surg. 2020;155(7):661–662. doi:10.1001/jamasurg.2020.0428
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