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Adventures in Neverland: challenges and alternatives.

Several of the articles in this month’s American Journal of Critical Care (AJCC) confront clinical problems that are considered “never events,” including medication errors and pressure ulcers. Ventilator-associated pneumonia and delirium have also been proposed as never events, although they are not yet officially classified as such. Excellence in critical care practice encompasses a continued quest for improvements in patient safety and quality of care, with a goal of better outcomes for patients. AACN has a strong commitment to excellence as reflected in its mission statement: “AACN drives excellence because nothing less is acceptable.” Excellence in patient safety and quality of care requires attention to both process and outcomes. Process and outcomes have been the focus of national safety and quality initiatives over the past decade. In 1999, the Institute of Medicine published To Err Is Human: Building a Safer Health System. This report highlighted the morbidity, mortality, and cost associated with preventable health care errors. This report also advocated for organizational attention to improving the delivery of care, and emphasized that many preventable errors could be directly linked to systemic process failures. Despite the increased attention, preventable errors continue to cost the United States an estimated 99,000 lives annually plus $17 billion to $29 billion per year in health care expenses, lost worker productivity, lost income, and disability. Never events were introduced into the clinical lexicon in 2002 by the National Quality Forum (NQF) report, Serious Reportable Events in Healthcare, and gained traction when they were linked to hospital reimbursement in 2008. NQF currently identifies 28 clinical problems as “serious, largely preventable, and of concern to patients and health care providers.” In 2007, the Centers for Medicare and Medicaid Services (CMS) identified a set of 8 “reasonably preventable” never events, and in 2008 began a policy of nonpayment to hospitals and providers for treatment of these events unless it could be documented that the condition was present on admission. The current CMS list has expanded to 10 hospital-acquired conditions (see Table). Other payers have followed the lead of CMS in denying payment for certain hospital-acquired conditions. Although NQF has recently removed references to the term “never events” and now refers to “serious reportable events,” the idea of never events is well established. Never events focus on important undesirable clinical outcomes. In an ideal world, never events would never happen. However, the real world of critical care is a more nuanced environment than Neverland, and several considerations are important in any discussion of never events. ©2011 American Association of Critical-Care Nurses doi: 10.4037/ajcc2011927