CMS Never Events: Research Report

Exploring the connection between tracking near misses, organizational learning and reducing never events in health care organizations

Health care organizations are facing mounting pressure from consumers, state governments, funders and the Centers for Medicare and Medicaid Services (CMS) to improve patient safety and embed more accountability and transparency. Health care organizations have been reporting adverse events for many years, yet a significant number of events still go unreported. This industry trend has lead to a more critical view of preventable and serious adverse events, coined “Never Events” by the National Quality Forum. The focus on tracking ‘near miss’ events is also a challenge, as some health care organizations do not see the value in tracking and analyzing them to identify deficiencies in patient safety initiatives.

This paper will propose how capturing and learning from near misses in health care organizations could lead to the prevention of actual adverse events. Also, how implementing an electronic system to manage this data can do the following: support CMS’ Never Event tracking, facilitate mandatory reporting requirements from governing bodies, heighten the success of patient safety initiatives and improve the culture of safety within health care organizations.