Hospital-Acquired Conditions: Important Terms to Know

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Automated clinical workflow: Technology that aims to improve the functionality of the health care system by streamlining the process and providing patients with the best health experience possible. This technology allows clinicians to perform jobs in less time or with less effort, which reduces the wait time for other tasks.

Care management Never Events: A type of Never Event related to improper, insufficient, or negligent clinical care. Examples include events resulting from medication errors, the administration of ABO-incompatible blood or blood products, and death or disability secondary to spinal manipulative therapy.

Criminal Never Events: A type of Never Event in which criminal conduct occurs. Examples include impersonation of a health care provider, abduction of a patient, and sexual assault.

Environmental hygiene: A basic principle of infection prevention in medicine. The surfaces of contaminated hospital equipment play an important role in infection by harboring microorganisms containing Clostridium difficile and multidrug-resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA). Proper hygiene of surfaces and equipment in contact with patients and medical professionals is necessary to reduce exposure.

Environmental Never Events: A type of Never Event resulting from deficiencies in the clinical environment. These events include patient death or disability from an electrical shock or from administration of the wrong medical gases or gases contaminated with toxic substances and patient deaths resulting from falls at the facility.

Hospital-acquired conditions (HACs): Conditions that arise while a patient is in the hospital or is being treated for an initial, separate illness. These conditions can cause significant patient harm and are generally preventable.

Never Events: Preventable errors occurring in the health care setting. The Centers for Medicare & Medicaid Services determined that they would no longer pay for the costs associated with these preventable errors. Never Events are categorized into six groups: surgical events, product or device events, patient protection events, care management events, environmental events, and criminal events. Never Events are not always 100% preventable.

Medical device–related pressure injuries (MDRPIs): Pressure injuries that develop from the use of medical devices. These injuries are considered a type of hospital-acquired condition and are classified as a Never Event. MDRPIs commonly occur over bony prominences.

Patient protection Never Events: A type of Never Event that stems from failure by the facility to protect the patient. These events include having an infant discharged to the wrong person and patient suicide during admission.

Present-on-admission (POA) pressure injuries: Pressure injuries that predate hospital admission. “Present on admission” means that the condition was present when the order for inpatient admission was placed. Pressure injuries that develop during outpatient contact, such as in an emergency department, during observation, or during outpatient surgery, are included in the POA definition.

Product or device Never Event: A Never Event related to the improper use of a medical product or device. Examples include patient death or disability related to the use of contaminated drugs or devices and patient death or disability associated with the use or function of a device in patient care where the device is used or functions other than as intended.

Surgical Never Event: A type of Never Event occurring during surgery. Examples can include leaving a surgical tool or object in a patient, performing surgery on the wrong patient, performing surgery on the wrong body part, or performing the wrong surgical procedure.

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