A Spotlight on Four Never Events
There are 29 medical errors that can occur in a hospital or medical care setting that should never happen. The National Quality Forum calls these 29 medical errors "never events," meaning, of course, that they should never happen and are largely preventable. Most of these mistakes are likely to happen while a patient is being cared for in a healthcare facility. Others can happen anywhere, including in a patient's home.
As an organization, Maxim Healthcare Services has been working diligently to continue to improve the level of quality care that we provide to our patients while simultaneously reducing the occurrence of "Never Events."
Today, hospital readmissions are a major concern in healthcare. Readmissions are attributed to a number of factors such as limited or no access to quality post-hospital care, inadequate discharge procedures, inadequate follow-up care, and preventable medical errors.
Wound development is a significant risk and a potential source of infection that is easily preventable. There are many types of wounds such as pressure ulcers (decubitus), neuropathic, vascular, and diabetic. Wound development is preventable through continuous assessments, patient monitoring, and plans of care that include pressure relief. If wounds do develop, prompt wound management can improve the rate of healing and reduce the chance of infection.
There are numerous infections that can occur in healthcare settings due to a variety of reasons such as increased use of antibiotics, vulnerability due to weakened immune systems, recent surgery or invasive procedures, and improper hand washing infection control. Many infections are device associated such as catheter-associated urinary tract infections, catheter-associated vascular infections, and tracheotomy with and without ventilator infections.
Falls and Injuries
National Quality Forum’s list of 29 never events includes falls and injuries due to falls. These falls can lead to serious injury such as fractures, traumatic brain injuries, nerve damage, muscle injury, or death.
How is Maxim Addressing Never Events?
- Working closely with the patient’s physician and healthcare team to ensure the plan of care post-discharge is implemented and adjusted as that patient’s needs change
- Educating our patients and their families
- Training our direct care staff on treatments and specific care signals
- Educating of direct care staff, family and patient in good hand washing techniques
- Monitoring condition improvements or regressions to ensure accuracy of plan of care
- Coordination of care by striving to match a caregiver’s experience to a patient’s needs
- Ensuring there is proper equipment and safety standards in place
- Monitoring incident reporting
- Implementing and addressing home safety assessments
- Prompt physician notification of change(s) in condition
- Continuous remediation to family and direct care staff of the importance of proper handwashing and adherence to standard precautions
- For patients at risk of skin breakdown-implementing pressure relief strategies
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