A Comprehensive Guide to Managing Never Events and Hospital-Acquired Conditions

Table of Contents

Part I: Overview

• Chapter 1. Historical Background
• Chapter 2. Background Statistics

Part II: Current Environment

• Chapter 3. Participants in the Process
• Chapter 4. Never Events and Hospital-Acquired Conditions

Part III: Impact and Solutions

• Chapter 5. The Impact of Preventable Adverse Events and Ways to Reduce Them

Part IV: Collaboration

• Chapter 6. Working with Providers
• Chapter 7. Value-Based Purchasing
• Chapter 8. Reporting Issues

Part V: Strategies for Reducing Never Events and Hospital-Acquired Conditions

• Chapter 9. The Keys to Adopting Best Practices
• Chapter 10. Creating a Patient Safety Culture

Part VI: The Patient Perspective

• Chapter 11. Health Literacy
• Chapter 12. Patient Impact

Part VII: The Future

• Chapter 13. Universal Data Collection and Reporting
• Chapter 14. What’s Ahead for Never Events and Hospital-Acquired Conditions

Appendix A. Web Sites

Appendix B. Abbreviations and Acronyms

Appendix C. Glossary

Written By

Robert F. Bunting, Jr., MSA, CPHRM, DFASHRM, CPHQ, MT (ASCP)
Mr. Bunting is a clinical research manager for WellPoint, Inc., who has more than 25 years of health care experience, including 10 years as the director of quality and risk management for a comprehensive health care system. Mr. Bunting received his clinical training as a medical laboratory scientist. His Bachelor of Science in Medical Technology and Master of Science in Administration in Health Care were awarded by Columbus State University in Columbus, Georgia. He has been the instructor of a graduate school risk management course for more than 10 years. Mr. Bunting served on the Editorial Board of the Journal of Nursing Risk Management, published by the Armed Forces Institute of Pathology, and currently serves on the Editorial Board of the Journal of Healthcare Risk Management, published by the American Society for Healthcare Risk Management (ASHRM). Mr. Bunting was the editor of the first three editions of ASHRM’s A Study Guide for the Certified Professional in Healthcare Risk Management (CPHRM) Examination.

Jay Schukman, MD, MSc
Dr. Schukman is the Regional Vice President and Senior Medical Director, East Region at Anthem Blue Cross and Blue Shield, Richmond, Virginia. He received his medical degree in 1975 at Kansas University School of Medicine in Kansas City, Kansas, and completed a residency in Family Medicine in 1978 at the Kansas University Medical Center in Kansas City, Kansas. He also received a Master of Science degree from the University of Wisconsin-Madison in Administrative and Preventive Medicine in 1994. Dr. Schukman is board-certified in family medicine. He was a clinical instructor in the Department of Family and Community Medicine at the University of Kansas School of Medicine from 1991 to 2000. Dr. Schukman was in the private practice of family medicine for 16 years. He is a member of the Richmond Academy of Medicine, the Medical Society of Virginia, and the American College of Physician Executives (ACPE), from which he holds the title of Certified Physician Executive.

Wesley B. Wong, MD, MMM
Dr. Wong is the Regional Vice President, Anthem National Accounts Medical Director, Central Region at Anthem Blue Cross and Blue Shield, Indianapolis, Indiana. He received his medical degree from the University of Oklahoma Health Sciences Center, Oklahoma City, in 1980. Dr. Wong is board-certified in neurology, electrodiagnostic medicine, and pain management, and was in private practice for 15 years. He served as the Medical Director of the Medical Specialties Service Line and Medical Director of the Neurosciences Service Line with the Indiana Neuroscience Institute at St. Vincent Hospital, one of the largest health systems in Ascension Health, the largest not-for-profit health delivery system in the country. Dr. Wong also led the Medication Safety Advisory Council for Ascension Health, during which time he was responsible for developing definitions of medication error, establishing common reporting systems, detecting errors, and achieving clinical measurements aimed at reducing medication errors and harm across 62 acute care hospitals.

Written For

Anyone who is responsible for ensuring safe patient care, including:

• Risk managers
• Patient safety officers
• Compliance officers
• Quality professionals
• Chief nursing officers
• Chief executive officers
• Chief financial officers
• Chief medical officers
• Hospital board members

… from hospitals, health systems and other health care providers, health plans, law firms, consulting firms, leading health care organizations as well as other leaders in the health care industry

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Review of the Publication by Industry Leaders

This book is much more than its title indicates. A rich compendium of information on the history and current state of patient safety, this guide also provides the context within which never events and HACs need to be understood to appreciate their importance to the overall goals of safe patient care. So well written that it would seem out of place in the reference section of your bookshelf, it is, nonetheless, a reference book of the highest quality and a must-read for those involved in this transformational work.

–Diane C. Pinakiewicz, President, National Patient Safety Foundation

An excellent reference for all health care providers, especially risk managers, patient safety officers, and quality professionals. As health care providers, we are all in this together, and this book provides an exceptional foundation upon which to build.

–Georgene Saliba, Administrator for Risk Management, Claims Management, and Patient Safety, Lehigh Valley Hospital and Health Network, and president of the American Society for Healthcare Risk Management

This book provides a broad-based review of preventable adverse events and sets forth human, technology, and culture-based solutions for reducing their occurrence with the ultimate goal of providing high quality, evidence-based care. The strategies, tips, and resources in this book are a welcome set of tools for health care providers and leaders alike.

–Kathleen Shostek, Senior Risk Management Analyst, ECRI Institute

An ambitious undertaking that actually succeeds in pulling together history, resources, and references with the readability of a novel, A Comprehensive Guide to Managing Never Events and Hospital-Acquired Conditions belongs on the shelf of every health care risk manager.

–Pamela L. Popp, Executive Vice President, Western Litigation Inc., and past president of ASHRM

Anyone charged with driving the patient safety initiative, or convincing staff, physicians, or boards of the importance of action in an organization, should read this book!

–Geri Amori, Vice President, Education Center, The Risk Management and Patient Safety Institute, and past president of ASHRM

A well-written and comprehensive review that should be a part of the library of every person who is serious about patient safety.

–Doug Borg, Director of Insurance, Duke University Health System, and past president of ASHRM