Does The Term "Never Event" Apply to Pressure Injuries?

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by Jeffrey M. Levine MD, AGSF, CWS-P

Editor's Note: The views expressed in Dr. Levine’s posts are solely those of the author, and do not represent the views of any medical school or national organization.

The term "never event" is commonly applied to pressure injuries, perpetuating the impression that they are always associated with medical error. The reality is that the preventability of all pressure related wounds has never been proven, and most authorities agree they can occur even in the best of circumstances. As such, the term "never event" lends this outcome an emotional charge that can lead to misplaced patient dissatisfaction and unnecessary accusations of wrongdoing or poor quality care.

Pressure Injuries and Serious Reportable Events

According to the Agency for Healthcare Research and Quality (AHRQ), the term "never event" was introduced in 2001 by the National Quality Forum (NQF) in reference to medical errors such as wrong-site surgery that should never happen. Over time, the list has grown to over 30 events that include stage 3 and 4 pressure ulcers that occur after admission to a health care facility. NQF has since softened up their language using the name "Serious Reportable Events" (SREs), but the term "never event" still appears on their website.

In an effort to cut spending and reward improved performance, in 2008 the Centers for Medicare and Medicaid Services (CMS) implemented policies that deny Medicare payment for specific hospital-acquired conditions (HACs). CMS does not recommend a total cost waiver, rather they require deferment of the Medicare Severity Diagnosis Related Groups (MS-DRG) code that increases complexity of the patient’s care. 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."

Nonetheless, both the National Quality Forum (NQF) and the Leapfrog Group continue to use the term "never event," which applies to a list that includes hospital-acquired stage 3 and 4 pressure ulcers. The Leapfrog Group is an organization that advocates quality health care, and publishes an annual hospital survey that assesses performance. The Leapfrog Group has a "Never Events Policy" that asks a hospital to commit four basic acts if a "never event" occurs: 1) apologize to the patient and family; 2) waive all costs related to the event and follow-up care; 3) report the even to an external agency, and 4) conduct a root-cause analysis of how and why the event occurred.

A Comparison of Outcomes

I certainly agree that reporting and root-cause analysis is important for any adverse outcome in a health care setting, but apologies and total cost waivers may be extreme if the outcome was an unavoidable consequence of the patient’s underlying illnesses.

Is it fair to compare all pressure injuries to wrong-site surgery and criminal events such as patient abduction? The term "never event," though expressing an ideal, may be unjustified for many pressure injuries – casting a shadow of wrongdoing or lapse in quality when efforts at prevention have been taken. Until it is proven that pressure ulcer rates can truly reach zero, this term will hold caregivers to an unrealistic standard.

About the Author
Dr. Jeffrey Levine is a board certified internist and geriatrician with over thirty years of experience in wound care in hospitals, nursing homes, and home care environments. He is Associate Professor of Geriatrics and Palliative Care at the Icahn School of Medicine at Mount Sinai, and has a hospital based wound care practice at the Center for Advanced Wound Care at Mount Sinai Beth Israel Medical Center in Manhattan. He received his fellowship training in geriatrics at the Mount Sinai Medical Center where he began his interest in chronic wounds. He is an elected board member of the National Pressure Ulcer Advisory Panel (NPUAP).

Dr. Levine’s interest in pressure ulcers began in the 1980s during his geriatric training when he noticed that many of his nursing home patients had pressure ulcers but there was little reliable information on treatment methods. This motivated him to study not just prevention and treatment of chronic wounds, but to delve into the rich history of wound care over the centuries. He has since published a number of articles on historical topics ranging from wound care in ancient Egypt through the 20th Century.

The views expressed in this post are solely those of the author, and do not represent the views of any medical school or national organization, WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

Comments

Hi Dr. Levine, After nursing all my life I find that the preventing pressure injury guidelines have not done enough to prevent pressure injuries.. I am sure that you are aware of Kosiak work in 1958 Mary Bliss (England). Catherine Sharp and Brenda Ramstadius Australia who have pioneered in Australia to try and prevent Pressure injuries. I know that the last 2 authors have been ignored in Australia and I see at last that Catherine Sharp is getting some recognition in England.
I agree with Catherine Sharp and Brenda Ramstadius that if we concentrate relieving pressure which is really the only factor that causes a pressure injury and we provide a good alternating pressure air mattress straight away (we cannot wait 8 hours) in our very sick and 'at risk' patients we will then prevent these nasty injuries. If incontinence caused a pressure injury then we would have vulva pressure injuries, Nutrition we don't see malnourished getting pressure injuries except if they cannot reposition. I have nursed many friction injuries on the heel and healed them by relieving the pressure straight away. Nurses address incontinence nutrition etc, if we concentrate on relieving the pressure skin checks as soon as the patient is admitted then regularly (provide the right equipment straight away) we can be successful. We should never ever be seeing grade 3 or 4 injuries. Thank you.

Hi Eileen, thanks for your comment. The NPUAP has done a wonderful job on defining the State of the Science for Unavoidable Pressure Injuries (see https://www.ncbi.nlm.nih.gov/pubmed/24901936). I agree that we can do better with prevention, however it is well recognized that there are irremediable risk factors that when combined with impaired physiology that compromises tissue tolerance, pressure injuries can and do occur even in the best of circumstances. In such cases caregivers should not be blamed.

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