You are attending a general meeting with management to discuss proposed changes in the Quality Assurance program secondary to a “never event” occurring in your organization [you can consider any never event offered by the AHRQ].

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First of all, let’s make sure we are on the same page. The term “never event” was first coined by Ken Kizer to refer to particularly shocking medical errors – things that should ‘never’ happen. These events are usually unambiguous errors (there is no question that it is a mistake), serious, and preventable. The National Quality Forum defined 27 never events in 2002. As of the 2011 revision, there are 29 events grouped in six categories (surgical, product or device, patient protection, care management, environmental, radiologic, and criminal).

Some examples of never events include:
– sexual assault of a patient
– infant discharged to the incorrect mother
– surgery on the wrong body part
– surgery on the wrong patient
– wrong blood type given during a transfusion, resulting in a hemolytic reaction

In response to a never event, the standard procedure is:
– apologize to the patient
– report the event
– perform a root cause analysis
– waive costs directly related to the event

For the purpose of your questions, the ‘never event’ that I am going to address is stage 3 or 4 pressure ulcers acquired after admission into a medical facility.

1) Considering that …