What Are "Never Events" and Whose Responsibility is it to Report it?

In 2008 the Centers for Medicare & Medicaid Services (CMS) issued a directive to the Medicaid/Medicare directors of all 50 states to explain that Medicare/Medicaid would no longer pay for medical care following a hospital or nursing home acquired malpractice. https://downloads.cms.gov/cmsgov/archived-downloads/smdl/downloads/smd073108.pdf

The CMS directive indicated the hospital or medical facility that caused the malpractice should be required to provide or pay for the post-malpractice medical care they caused.

The CMS directive announced that Medicare would no longer pay the higher MS-DRG extra cost of treating the following categories of conditions while the patient is in the hospital:

• pressure ulcer stages III and IV;

• falls and trauma;

• surgical site infection after bariatric surgery & certain orthopedic procedures;

• vascular-catheter associated infection;

• catheter-associated urinary tract infection;

• administration of incompatible blood;

• air embolism; and

• foreign object unintentionally retained after surgery.

These conditions are sometimes called “Never Events” because they should never happen if hospitals or medical institutions follow their own safety precautions. CMS defines “never events” as “errors in medical care that are clearly identifiable, preventable, and serious in consequence for patients and indicate a real problem in the safety and credibility of a healthcare facility”.

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