Safeguarding Against Nursing Never Events

Best Practices for Preventing Pressure Ulcers and Patient Falls

Topics: Nursing, Never Event, Medical Errors, Quality, Performance Improvement, Safety

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By whatever measure, pressure ulcers and patients falls—referred to as "never events"—are usually thought of as nursing's greatest quality challenges. This study will help hospitals and health systems reduce their occurrence by laying the groundwork for accurate treatment and diagnosis through:

  • Targeting trouble spots such as toileting protocols to improve patient outcomes and streamline workflow
  • Examining support structures and developing effective ways to build the infrastructure necessary to ensure patient safety
  • Looking to the future for innovative breakthroughs to lower cost and improve clinical outcomes

Executive Summary

Targeting Nursing's Top Quality Challenges

Hospital and health system executives are all too familiar with the recent proliferation of quality indicators that must now be tracked, reported, or avoided. This lengthy set of measures is the sum of listings set forth by various health care organizations aiming to improve hospital care quality, including the National Quality Forum, the Agency for Healthcare Research and Quality, the Joint Commission, and the National Database of Nursing Quality Indicators. Of all the measures endorsed by these organizations, pressure ulcers and patients falls are almost universally considered nursing’s greatest quality challenges. They are among the most costly, most prevalent, and most widely endorsed of all nursing-sensitive quality indicators, and therefore the focus of this report.

Building the Business Case for Prevention

Since both pressure ulcers and patient falls have also been included in CMS' listing of 11 hospital-acquired conditions, these indicators have captured the national spotlight because of their potential impact on hospital reimbursement. Hospitals are now subject to potentially reduced reimbursement rates if these conditions are not documented as "Present on Admission." The Nursing Executive Center has analyzed hospital Medicare data to provide projections of the national worst-case hospital revenue at risk, which fortunately is far less severe than many hospital executives originally anticipated. Interestingly, the incremental costs associated with the treatment of these conditions actually far exceed the total revenue at risk, offsetting any perceived gains from reimbursement. The biggest financial challenge, then - as well as the greatest opportunity - appears to be preventing pressure ulcers and falls from occurring in the first place. Put another way, the strongest business case here is the case for investing in prevention.

Striving for Zero-Defect Across Multiple Indicators

As part of this research initiative, Center researchers interviewed literally hundreds of organizations in an attempt to isolate best practices in preventing both pressure ulcers and patient falls. Although numerous institutions reported achieving zero-defect results on either one indicator or the other, we found very few institutions that had been able to achieve and sustain zero-defect performance on both simultaneously. As the list of indicators affecting hospital quality, finance, and reputation continues to grow, the Nursing Executive Center cautions that organizations can no longer afford to approach each quality challenge one indicator at a time. Rather, we believe the lessons gleaned from one indicator can and should be applied to the prevention of other indicators, as well.

Developing a Common Strategic Framework

In this research, we present a single strategic framework, featuring four high-level prevention imperatives, for safeguarding against nursing "never events." We highlight specific best practices that illustrate the application of each imperative to the prevention of pressure ulcers and patient falls, but the imperatives comprising the overarching framework may be applied to other nursing indicators as well.