According to AHRQ, “the term ‘never event’ was first introduced in 2001 by Ken K

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.
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.
For this assignment, you will select a never event from the list provided on AHRQ’s Never EventsLinks to an external site. webpage. 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.