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Put an end to 'never events'

February 1, 2010
by Maureen Hrehocik, Editor
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The North American Nursing Diagnosis Association International (NANDA-I) would like to put an end to “never events” by using stan-dardized terminology to document a registered nurse's diagnosis and care plan for a patient. Now let's back up a minute. I had never heard of the term never events. Never events are events that are never supposed to happen in a hospital setting, but frequently do-such as falls, foreign objects being left in a patient's body after surgery, infants being discharged to the wrong person, or patient death or serious disability associated with a medication error. Long-term care facilities have many of these same never events happening every day. Would standardized terminology help to forestall a fall or a resident getting the wrong medication? I don't know the answer to that, but it sure seems like it wouldn't hurt. When has clarity in communication ever been a bad thing?

NANDA-I is a professional nursing association that develops, refines, and publishes terminology that accurately reflects nurses' clinical judgments. Its director, T. Heather Herdman, PhD, RN, says the bottom line is that standardized nursing language is directly related to safe and effective care for patients (and residents). “A patient care plan written in a language that is understood by all will reduce the risk of never events. It is critical that this point is not lost as we tackle avoidable errors in patient [resident] care.”

And if patient safety and well-being wasn't enough of an incentive, Medicare contends that because these never events are considered preventable, healthcare providers must accept responsibility, accountability, and liability.

I urge you to meet with your director of nursing and find out just how stan-dardized your nursing terminology is. Are your nurses speaking the same language? Is there a standardized way to enter notes into the resident's record? Across-the-board conformity can go a long way to ensuring the best care possible within your facility as well as in other facilities if the resident needs to be transferred. Some things are just better in black and white.

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Maureen Hrehocik, Editor Long-Term Living 2010 February;59(2):8

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