![]() Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person.Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care setting.Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used for functions other than as intended.Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the health care setting.Intraoperative or immediately postoperative/postprocedure death in an American Society of Anesthesiologists Class I patient.Unintended retention of a foreign object in a patient after surgery or other procedure.Wrong surgical or other invasive procedure performed on a patient.Surgery or other invasive procedure performed on the wrong patient.Surgery or other invasive procedure performed on the wrong body part. ![]() National Quality Forum List of Serious Reportable Events, 2016 Since the initial never event list was developed in 2002, it has been revised multiple times, and now consists of 29 "serious reportable events" grouped into 7 categories: Over time, the term's use has expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. ![]() Reporting may be difficult.The term "Never Event" was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors-such as wrong-site surgery-that should never occur. The perception of some nurses is that violence in the workplace is "part of the job," which is given as a reason for not reporting such incidents. Consistent with under-reporting, Ulrich and Kear (2018) found more than 40% of nurses in nephrology settings said they did not report incidents of abuse, either because it did not seem to be a major issue or they thought nothing would be done about it. Hospital workers reported 68 occurrences of rape, homicide, or assault over an eight-year period, although the number of incidents is thought to be grossly underreported (TJC, 2018a). Behaviors can range from verbal threats or abuse to actual physical contact and violence that may include homicide (OSHA, n.d.). What is workplace violence? The Occupational Safety and Health Administration (OSHA) (n.d.) defines it as "any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site" (p. Such events require immediate intervention and subsequent analysis as to the underlying etiology, hence the term, sentinel (TJC, 2018b). TJC defines a sentinel event as a patient safety event reaching the patient that leads to death, permanent harm, or severe temporary harm, requiring intervention(s) to sustain life (TJC, 2018b). The continuing efforts of TJC recently led to the release of a Sentinel Event Alert addressing this issue to facilitate the management of violence and how to address the aftermath (TJC, 2018a). Ulrich and Kear (2018) address some of these issues in their landmark study in the nephrology environment, and this article discusses recommendations put forth by The Joint Commission (TJC). Workplace violence, encompassing both physical and verbal abuse, has become a topic of increasing discussion and focus, especially in the healthcare arena, as the problem has become more pervasive.
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