2023 Never events were among the many safety initiatives that that came out of the 1999 IOM report

Never events were among the many safety initiatives that that came   out of the 1999 IOM report. There are currently 28 Never Events. These   events are usually preventable, concern to both public and healthcare   professionals, clear cut, clearly identifiable, measurable, and can be   included in a report. The risk is related to policies and procedures,   serious, resulting in death, loss of body part, and disability. It is   adverse, and indicative of a problem with health facilities, and   important for integrity and public accountability. These events are   aptly named “never events”, as they should never happen.   If protocols and procedures are put in place to prevent these errors,   and healthcare staff and providers are following these policies and   procedures then these events should never happen. 

Centers for Medicare and Medicaid (CMS) announced that federal payor   programs will no longer reimburse for treatment of complications   related to care. These events are “reasonably preventable if   following evidence based guidelines” (O’Rourke, P. T.,   2009). Inadequate nurse staffing has been associated with higher rates   of adverse events. “The effectiveness of nurse surveillance is   influenced by the number of RN’s available to assess patients on   an ongoing basis (Di Leonardi, B.C., Faller, M., & Siroky, K.   n.d.). CMS offers nurses the opportunity to take on a leadership role   in preventing never events (A., 2010). The ability of nurses to   prevent medical errors in more than half of all never events are   nursing sensitive, especially falls and ulcers. Nurses are now viewed   as an investment and this is because when nursing staff is increases,   patient care improves (A., 2010).

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