Never Events. Serious name. Serious incidences.

Coined by Dr. Ken Kizer, former CEO of the National Quality Forum (NQF), the term “never event” was originally used to refer to a particularly shocking slate of medical errors that were both clinically devastating and largely preventable (such as wrong-site surgery). Over time, the list has grown to include 29 events grouped into 6 categories, each fulfilling three criteria, namely they are (i) unambiguous (clearly identifiable and measurable), (ii) serious (resulting in death or significant disability), and (iii) usually preventable.

In 2013 the NQF declared pressure ulcers (aka bedsores) a never event, more specifically, “stage 3 and 4 pressure ulcers that occur after admission to a healthcare facility”; yet despite this benchmark, pressure ulcers remain the fourth leading preventable medical error in the United States. Indeed, in Minnesota, where reporting of never events is required, pressure ulcers accounted for 39% of the events, reported in 2007-2008.

Pressure ulcers affect as many as 2.5 million patients in acute care facilities nationwide.

There is some debate as to whether or not pressure ulcers are wholly inexcusable or an outcome that can occur in the best of circumstances, however, one thing is certain: the incidence of severe pressure ulcers can have devastating effects on both the patient and the medical provider, with implications that encompass both the physical and the financial realm.

Pressure Ulcers: A Quick Review

Pressure ulcers go by many names: deep wounds, pressure sores, bedsores, pressure wounds – the monikers may change, but the danger remains the same. These tissue injuries (which can range from moderate to severe) are quick to develop but, if caught early, can be relatively simple to treat. Left untreated, they can lead to severe complications including sepsis, cellulitis, bone and joint infection, and in some cases, even cancer. For a more in-depth look at the signs and symptoms of pressure ulcers, take a look at this post.

When Pressure Ulcers Go Awry

Google “stage 4 pressure wounds” and you’ll come face to face with images that will sear into your retina, permanently implanting themselves into the reptilian fight-or-flight section of your brain that controls fear and pain. Let us save you the trouble and confirm, from the outset, that, left untreated, pressure ulcers can go seriously, terribly awry.

In the most extreme cases (stage 3 and 4), pressure wounds can become deep craters exposing muscle and bone. And, as previously mentioned, a progression of the condition can lead to severe complications including sepsis, cellulitis, bone and joint infection, and cancer. Clearly, this is something every care provider would like to prevent, and with the designation of “never event”, it’s clear the NQF believes that prevention is a realistic goal.

The Great Debate

While the NQF may have declared pressure ulcers a never event (meaning, with constant caregiver dedication and the implementation of adequate skin and wound management, prevention is indeed possible), not everyone is convinced. According to this article, “the avoidability of pressure ulcers has been debated since the time of Jean Martin Charcot in the 19th century, and the controversy continues to this day. Experts acknowledge that even with appropriate preventive interventions, there may be irreversible or unmodifiable comorbidities and risk factors that render pressure ulcers unavoidable.”

On the other hand, there is a great deal of evidence to support the conclusion that pressure ulcers are an avoidable occurrence. For instance, by instituting a practice dubbed “Mayo Clinic Patient Safety Essentials,” the preeminent medical facility was able to reduce its advanced pressure ulcer rate to 1/60th the national average. And yet the debate still continues because even the Mayo Clinic acknowledges a continued struggle to further reduce the frequency of pressure ulcers, noting that, just as patients may suffer lung, kidney, and heart failure, they may also suffer skin failure when all known prevention methods have been employed and failed.

Medicare Denial: The Financial Implications of Never Events

Beyond the physical implications, there are financial repercussions for pressure wounds acquired while in the care of a medical facility. Let’s take a look at how that came to be.

In November 1999 the Institute of Medicine (IOM) released a report titled, To Err Is Human: Building a Safer Health System. The report stated that medical errors, particularly hospital-acquired conditions (HACs), could be responsible for as many as 98,000 deaths annually, at costs of up to $29 billion.

In 2006, the U.S. Congress passed the Deficit Reduction Act of 2005, authorizing the Centers for Medicare and Medicaid Services (CMS) to adjust hospital payments to encourage prevention of HACs.

In June of 2007, the CMS proposed to deny Medicare payment for costly and sometimes deadly preventable HACs, beginning with eight conditions that would be subject to non-payment if any of them constituted complicating conditions for a patient. The list included stage 3 and 4 pressure ulcers.

Today, the incidence of pressure wounds can greatly affect hospital policy. Aside from the payment implications, the CMS decision to adjust hospital payments to encourage prevention of HACs affects the liability risk of any person providing inpatient care. To guard against this and protect both the patient and the medical provider, physicians and caregivers must remain vigilant in employing every possible precaution to prevent “never event” complications. In the end, it remains in everyone’s interest to do so.

For more information on proactive, preventive medicine, turn to MD at Home, the premier healthcare resource for primary care and geriatric medicine for homebound patients in the Chicagoland area.