Description
Never Events
[WLOs: 2, 3, 4, 5] [CLOs: 1, 2, 3, 4, 5]
Prior to beginning work on this assignment, read Chapters 3 and 7 from the course text, review The Joint Commission E-dition Database, and review the remaining chapters previously assigned in class. Additionally, read the following:
The Joint Commission Standards And Never Events
Never Events
Eliminating Serious, Preventable, and Costly Medical Errors – Never Events
How to improve
Save PowerPoint presentation as a PDF with notes showing
BACKGROUND:
According to AHRQ, “the term ‘never event’ was first introduced in 2001 by Ken Kizer, M.D., former CEO of National Quality Forum (NQF), in reference to particularly shocking medical errors – such as wrong-site surgery – that should never occur” (2019, para. 1). The Centers for Medicare and Medicaid Services (CMS) indicates a never event is an easily identifiable and preventable injury (2006). In 2003, the Joint Commission incorporated never events into their list of sentinel events which are defined as a “patient safety event that results in death, permanent harms, or severe temporary harm” to a patient and/or a health care provider (n.d., para. 1). This assignment will focus on never events even though these are often used interchangeably.
SCENARIO:
You are the quality director in a hospital. Last week, a never event occurred at your hospital. As the quality director, you must prepare a PowerPoint to present to the Quality Improvement Committee that describes the event that occurred, identifies the cause(s) of the event using either a fishbone diagram or Pareto chart, presents historical statistics that indicate how often the type of event occurs, and explains a process flowchart you will create that illustrates the steps that will be implemented to prevent the event from occurring again in the future.
DIRECTIONS:
For this assignment, you will select a never event from the list provided on AHRQ’s Never Eventswebpage. These are grouped under the primary topics of surgical or procedural events, product or device events, patient protection events, care management events, environmental events, radiologic events, and criminal events. You will prepare a 15 to 20-slide PowerPoint presentation with four to seven bullet points on each slide that briefly explain the topics covered. Include detailed speaker’s notes of 150+ words for each slide, not including the title and reference slides. Please see the HCA375 PowerPoint Instructionsdocument for expanded information on expected details in your presentation.
In your presentation, include
Title Slide
Select a topic of your choice from AHRQ’s Never Events webpage.
Create a title slide that includes as your title the never event selected. In this slide’s speaker notes, include your introductory information (e.g., your degree, any health care experience and/or qualifications you have, your purpose for this presentation).
Content Slides
Explain the history of the event.
Include statistical details as to how often the event occurs across the country.
Include the types of harm that can occur to patients during this event.
Discuss accreditation agency recommendations for avoiding this type of never event.
Include a list of at least three accreditation agency recommendations. These can be from the Joint Commission standards, NCQA, CLIA, CMS, etc.
Include your rationale for why you believe these recommendations are important to prevent the never event from occurring.
Analyze the cost/quality impact of the event on the patient and the hospital.
Include potential harm to the patient.
Include potential financial loss to the hospital (e.g., lawsuit, reputation, etc.).
Create a fishbone diagram to identify at least four possible root causes for the never event.
You may use this accessible PPT fishbone diagram.
When you have added the details, in Normal view, put your mouse on the finished diagram slide in the left (slide navigation) column and right-click to copy the slide, then paste it into the left (slide navigation) column of your PowerPoint file.
Explain the procedures that should be followed to ensure the never event does not occur again at your hospital.
Choose the best CQI method that could be used to eliminate the event from recurring (e.g., Lean, Six Sigma, Lean-Six-Sigma, PDSA, etc.).
Provide a rationale as to why you selected the CQI method.
Include details about how the procedures will be used in the never event scenario by applying the steps to the event.
Create a process flow diagram (flowchart) to show the recommended process(es) or steps that must be followed to avoid this event in the future.
Include the type(s) of intervention(s) needed to correct the problem (e.g., reducing human error, reducing procedural errors, etc.).
How to Add a Flow Chart to a Slide in PowerPoint
How to Create a SmartArt graphic from scratch (if you prefer to do your own shapes)
Discuss how you will monitor, evaluate, and control the improvement plan.
Include details regarding whether the results are sustainable over time.
Include whether modifications are needed to maintain the improvement.
Include details regarding avoiding drift (e.g., returning to old ways of doing things, which caused the event).
The Never Event presentation
must be 15 to 20 PowerPoint slides in length (not including title and references slides) and formatted according to APA Style as outlined in the Writing Center’s How to Make a PowerPoint Presentation resource.
must include a separate title slide with the following in title case:
title of presentation in bold font
Space should appear between the title and the rest of the information on the title page.
student’s name
name of institution (The University of Arizona Global Campus)
course name and number
instructor’s name
due date
must include speaker’s notes of 150+ words for each slide.
must include images that help convey the message in your presentation.
must utilize academic voice.
See the Academic Voice resource for additional guidance.
must use at least five credible sources in addition to the course text.
The Scholarly, Peer-Reviewed, and Other Credible Sources table offers additional guidance on appropriate source types. If you have questions about whether a specific source is appropriate for this assignment, please contact your instructor. Your instructor has the final say about the appropriateness of a specific source.
To assist you in completing the research required for this assignment, view Quick and Easy Library Researchtutorial, which introduces the University of Arizona Global Campus Library and the research process, and provides some library search tips.
must document any information used from sources in APA Style as outlined in the Writing Center’s APA: Citing Within Your Paper guide.
must incorporate visual images and/or design elements that make the presentation pleasing to the eye.
must include a separate references slide that is formatted according to APA Style as outlined in the Writing Center.
See the APA: Formatting Your References List resource in the Writing Center for specifications.
REFERENCES:
Agency for Healthcare Research and Quality (AHRQ). (2019). Never Events. https://psnet.ahrq.gov/primer/never-events
Centers for Medicare and Medicaid Services (CMS). (2006). Eliminating serious, preventable, and costly medical errors – Never Events. https://www.cms.gov/newsroom/fact-sheets/eliminati…
Joint Commission. (n.d.). Sentinel event. https://www.jointcommission.org/resources/sentinel…
