Return to Never Events Collaborative
Never Events

The following are ways a patient and their advocate can take an active role in their healthcare and prevent hospital acquired conditions:

Four Pillers of Control for HAIsWith healthcare integration, the physician is rapidly becoming an employee rather than an important customer.  This may produce a conflict of interest, one which may inhibit advocacy.   In organizations, an important customer often has more clout in implementing change and advocating than an employee.

A recent White Paper from the CDC (Centers for Disease Control), SHEA (Society for Healthcare Epidemiology of America), APIC (Association for Professionals in Infection Control and Epidemiology, ASTHO (Association of State and Territorial Epidemiologists), CSTE (The Council of State and Territorial Epidemiologists), and the PIDS (Pediatric Infectious Disease Society) stated the following:1

“The combined tools of healthcare payment, oversight and accreditation, and public reporting are emerging ways to increase adherence to HAI prevention practices.”


  1. Quality:  Patient Action and Preparedness Before and while Receiving Medical Care - What to look for in a care provider and how to monitor the care you receive.  The website  can aid in this process. 

    1. Always have a health Advocate.

    2. Ask to have yourself screened for MRSA, especially if you are having surgery.  Scrub your body with an antibacterial soap or prescribed solution before having surgery.

    3. Ask if the facility uses checklists for surgery and the insertion of central lines.

    4. Have your health advocate keep track of all medications you are given.  Ask what is going to be given, why it is needed,  and the dosage before it is administered. No how frequent the medication is to be given.

    5. Always make sure everyone including your doctor and visitors wash their hands when entering the room.  Remember alcohol rubs do not kill C. Difficile spores. Soap and water is best for washing hands.

    6. If you have a urinary catheter in your bladder, make sure it is removed as soon as possible. 

    7. Make sure your room is cleaned.  The bathroom should be cleaned with bleach, or a comparable sporicidal product, at least once during the beginning of your stay.  If it wasn't ask for this to be done.

    8. Make sure your room is cleaned every day.

    9. Adequate Nursing Staff - Nurse-to-Patient Ratios and adequate nursing staffing are very important.  Ask your nurse if she is overworked and how many patients she is caring for.   Is your nurse a registered nurse or a nurse's aid. More on the Importance of Nursing

  2. Costs:  Get quotes and price your tests and upcoming stay with different comparable institutions.  Costs can vary by as much as 100% . 

  3. Public Reporting;  Public reporting of hospital acquired conditions and hospital acquired infections is mandatory in 28 states and supported by major medical organizations and the Center's for Disease Control as being a key part in their prevention. 

    Download Document of Major Medical Organization Support 

    Download Document of CDC Support 

    In response to the question what will really cause a change, Dr Mark Chassin replied: “that the pressure will have to come from the public in the same way that public pressure created environmental protection laws. Someone needs to call attention to patient safety the way Rachel Carson warned of environmental disaster in (the book) Silent Spring."  (Columbia Journalism Review, Sept 2, 2010) 

    The director of the CDC's HAI prevention program, Dr. Srinivasan, recently stated that the “CDC does believe that increased transparency, public reporting of healthcare-associated infections is an important part of a comprehensive effort to prevent healthcare-associated infections and eliminate these infections ...”  

    The White Paper from the CDC, SHEA, APIC , ASTHO, CSTE, and PIDS stated the following:1

  4. “Measurement can also provide institutions and the public with information for comparisons across facilities and regions to better understand current risks for HAIs as well as risks over time.”

    “Public health departments, working with HAI prevention experts, need to establish and to maintain strong programs in HAI elimination.”

    “Data also allow public health officials to identify local and regional facilities requiring improvement”

    England and France have instituted mandatory public reporting.2   

  5. Economic Incentives - Nonpayment for unanticipated and largely preventable adverse events has become a cornerstone in the healthcare policy of the CDC and many insurance companies.  This policy has the advantage of both saving the healthcare dollar and promoting quality.

  6. Self reporting initiatives of Adverse Events have not been viewed as being effective with only a small fraction of the occurrences actually being reported. 

    1. The Joint Commission estimates that only 1% of Sentinel Events are reported.3   Since January 1995, there have only been 4,347 Sentinel Events reported to the Joint Commission.4

    2. AHRQ found that 48% of surveyed facilities did not report any events (sentinel or otherwise) -- 614 hospitals with 143,052 respondents.5

    3. Half of the US Hospitals have never reported a physician to the National Physician Data Bank.6  The Bank was established in 1986.

    4. State regulators in California have found 87 hospitals that have not reported a serious medical error in three years. By California State Law hospitals are required to report any of 28 designated adverse medical events.7

      Hospital Affairs reported a study on three leading hospitals in Utah and found that over 90% of adverse events are missed when detected through self reporting.8

  7. Medicine should better stand behind their product similar to other industries.   Not all events are preventable but many are.   Accountable Care Organizations are starting to emerge and are designed to have the provider take the performance risk and the insurance company take the insurance risk.  Thus, the risk is shared.   American Medical News found that almost 80% of more than 50 businesses felt that hospital acquired conditions should not be paid for by the insurance company.9


  1. Cardo D, Dennehy PH, Halverson P, Fishman N, Kohn M, Murphy CL, Whitley Rj,  and the HAI Elimination White Paper Writing Group.   Moving toward elimination of healthcare-associated infections:  A call to action.   Oct 7, 2010.

  2. Struelens MJ, Monnet DL.  Prevention of Methicillin-Resistant Staphylococcus aureus Infection:  Is Europe Winning the Fight?  Infection Control and Epidemiology.  2010 Oct;31(51): 

  3. Levinson DR. Adverse Events in Hospital: Overview of key issues. Dept. of Health and Human Services, Office of Inspector General. Dec 2008, Page 25 

  4. Sentinel Event Statistics. The Joint Commission. September 30, 2009. 

  5. Sorras J. Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report . AHRQ March 2009 

  6. Sorrel AL. When is conduct reportable? National Practitioner Data Bank takes complaints from hospitals about physicians. American Medical News Sept 21, 2009 

  7. State Health Regulators Urge Some Hospitals To Recheck Error Reporting.  California Healthline.   Nov 18, 2010.

  8. Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A and James BC. ‘Global Trigger Tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs. April 2011 p 581-589. 

  9. Employers support nonpayment for "never events". News in brief. American Medical News. March 23, 2009