Never 27 Events

Lately I have been immersing myself with understanding this new initiative called “Never 27 Events.”  In essence these are adverse patients events that occur during a hospital stay, that should “never” happen.

For instance, if a patient developed a pressure ulcer during his/her inpatient admission, it will be difficult to get reimbursed for these at a higher DRG.

Here is a link I found that highlights the “Never 27″ initiatives.

These are the things that are shaping Healthcare and are pressuring organizations to take a close look at their documenation.  At my organization, we are implementing a evidenced base documenation model to facilitate better documenatation.  We are moving forward with a electronic format, so that it will also make it easier for administration to assess competency of the clinical staff in terms of documenatation.

Being in Healthcare IT, a came across an interesting Podcast by Spencer Hamons who is the Chief Information Officer for the San Luis Valley Regional Medical Center in Alamosa, Colorado. 

He proposed utilizing the same concepts of the “Never 27″ events and apply it to IT.  Here is what he has proposed thus far:

1. Patient harm as a result of wrong electronic data
2. Intentional patient information disclosure by employees

I chimed in on this discussion and came up with several of my own IT related “never” events.

1. Downtime of Clinical or Patient-centric systems greater than 8 hours
2. Critical issues unresolved without at least a work-around for more than 48 hours
3. Telling customers, “That is not my job.”
4. Never be an early adopter of new technology.
5. Never over promise.
6. Never utilize technology as a barrier for bad customer service.

Above are just a few of my suggestions, I hope to collect more and collaborate with Spencer and his list of IT Never Events…so please do send me any of your suggestions for our list.

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