Never Events and State Policies

Published by admin September 29th, 2008 in News.

States

Click on your state to find out more information and whom to contact.

  • Alabama
    • Policy: Yes. Will not charge patients or insurers for 11 preventable errors:
    • Surgery on the wrong body part.
    • Surgery on wrong patient.
    • Wrong surgery performed
    • Unintended object left behind after surgery.
    • Patient death or disability caused by air embolism that occurs in a health care facility.
    • Patient death or disability caused by incompatible blood or blood products.
    • Hospital-acquired stage 3 or 4 pressure ulcers.
    • Hospital-acquired catheter associated urinary tract infections.
    • Hospital-acquired vascular catheter associated infections.
    • Hospital-acquired mediastinitis after coronary artery bypass surgery.
    • Serious injuries caused by falls and trauma, including burns.
  • Alaska
    • Policy: No current policy.
  • Arizona
    • Policy: No current policy.
  • Arkansas
    • Policy: No current policy.
  • California
    • Policy: No current policy.
  • Colorado
    • Policy: Yes. Hospitals will consider not billing for 28 serious, preventable events identified by the National Quality Forum, a nonprofit patient safety and advocacy agency.
  • Connecticut
    • Policy: No current policy.
  • Delaware
    • Policy: Yes. Nine events covered:
    • Surgery on wrong body part.
    • Surgery on wrong patient.
    • Wrong surgery performed.
    • Retention of foreign object not designed to be retained in body.
    • Incompatible blood-associated injury.
    • Air embolism-associated injury.
    • Medication error leading to serious injury or death.
    • Artificial insemination/wrong donor.
    • Newborn infant discharged to wrong family.
  • District of Columbia
    • Policy: No current policy.
  • Florida
    • Policy: No current policy.
  • Georgia
    • Policy: Yes. Does not bill patients or insurers for 10 preventable events:
    • Surgery performed on the wrong body part.
    • Surgery performed on the wrong patient.
    • Wrong surgery performed.
    • Unintended retention of a foreign object in a patient after surgery or other procedure.
    • Patient death or serious disability associated with a medication error.
    • Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a health care facility.
    • Infant discharged to wrong person.
    • Patient death or serious disability associated with a reaction due to incompatible blood or blood products.
    • Patient death or serious disability associated with failure to identify and treat hyperbilirubinemia in neonates.
    • Stage 3 or 4 pressure ulcers acquired after admission to a health care facility.
  • Hawaii
    • Policy: No current policy.
  • Idaho
    • Policy: No current policy.
  • Illinois
    • Policy: No current policy.
  • Indiana
    • Policy: Yes. Adopted policy that urges hospitals to waive fees for 12 preventable errors:
    • Surgery performed on a wrong body part.
    • Surgery performed on a wrong patient.
    • Wrong surgery performed on a patient.
    • Unintended retention of a foreign object.
    • Patient death or serious disability associated with an air embolism that occurs while being treated in a hospital.
    • Patient death or serious disability associated with a reaction to the administration of incompatible blood or blood products.
    • Stage 3 or 4 pressure ulcers acquired after admission.
    • Patient death or serious disability associated with a fall or trauma after admission.
    • Patient death or serious disability associated with catheter-associated urinary tract infections.
    • Patient death or serious disability associated with vascular catheter-associated infection.
    • Patient death or serious disability associated with surgical site infection mediastinitis after a coronary artery bypass graft.
    • Patient death or disability associated with a medication error.
  • Iowa
    • Policy: No current policy.
  • Kansas
    • Policy: Yes. Does not bill for at least seven preventable errors
    • Surgery on wrong body part.
    • Surgery on wrong patient.
    • Wrong surgical procedure.
    • Retention of a foreign object.
    • Air embolism-associated injury.
    • Incompatible blood-associated injury.
    • Medication error resulting in serious disability or death.
    • In addition, any event that results in increased length of stay, level of care or significant intervention, or if additional procedures are required to correct problems listed above, or if re-admission is required as a result of a serious event in the same facility.
  • Kentucky
    • Policy: Yes. Does not bill for 14 preventable errors:
    • Surgery on the wrong body part.
    • Surgery on the wrong patient.
    • Wrong surgical procedure performed on a patient.
    • Unintended retention of a foreign object in a patient after surgery.
    • Patient death or serious disability associated with air embolism that occurs while being treated in a health care facility.
    • Patient death or serious disability caused by a medication error.
    • Patient death or serious disability caused by reaction to incompatible blood or blood products.
    • Artificial insemination with the wrong donor sperm or egg.
    • Infant discharged to the wrong person.
    • Death or serious disability associated with failure to identify and treat hyperbilirubinemia in neonates.
    • Patient death or serious disability associated with an electric shock while being cared for in a health care facility.
    • Patient death or serious disability in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaiminated by toxic substances.
    • Patient death or serious disability associated with a burn while being cared for in a health care facility.
    • Patient death or serious disability associated with the use of restraints while being cared for in a health care facility.
  • Louisiana
    • Policy: No current policy.
  • Maine
    • Policy: Yes. Does not bill for 28 serious, preventable events defined by the National Quality Forum, a nonprofit health care safety advocacy agency.
  • Maryland
    • Policy: No current policy.
  • Massachusetts
    • Policy: Yes. Does not charge patients or health plans for 28 serious, preventable events identified by the National Quality Forum, a nonprofit health care safety advocacy agency.
  • Michigan
    • Policy: Yes. Does not charge patients or health plans for 11 preventable errors.
    • Object left behind after surgery.
    • Air embolism as a result of surgery.
    • Blood incompatibility.
    • Stage 3 or 4 pressure sores.
    • Surgery on the wrong patient.
    • Surgery on the wrong body part.
    • Wrong surgery.
    • Catheter-associated urinary tract infections.
    • Vascular catheter-associated infections.
    • Surgical site infection associated with coronary artery bypass graft surgery.
    • Hospital acquired falls and burns.
  • Minnesota
    • Policy: Yes. Does not bill patients or insurers for 27 serious, preventable events identified by the National Quality Forum, a nonprofit health care safety advocacy agency.
  • Mississippi
    • Policy: No current policy.
  • Missouri
    • Policy: Yes. Does not bill patients or insurers for 28 preventable errors identified by the National Quality Forum, a nonprofit health care safety advocacy agency.
  • Montana
    • Policy: No current policy.
  • Nebraska
    • Policy: No current policy.
  • Nevada
    • Policy: No current policy.
  • New Hampshire
    • Policy: No current policy.
  • New Jersey
    • Policy: No current policy.
  • New Mexico
    • Policy: No current policy.
  • New York
    • Policy: Yes. Will not bill for eight preventable errors:
    • Surgery on the wrong body part.
    • Surgery on the wrong patient.
    • Wrong surgery.
    • Unintended retention of a foreign object after surgery or other procedure.
    • Patient death or serious disability associated with an air embolism.
    • Patient death or serious disability associated with a medication error.
    • Patient death or serious disability associated with incompatible blood or blood products.
    • Artificial insemination with the wrong donor sperm or the wrong egg.
  • North Carolina
    • Policy: No current policy.
  • North Dakota
    • Policy: No current policy.
  • Ohio
    • Policy: No current policy.
  • Oklahoma
    • Policy: Yes. Hospitals will not bill for 11 serious, preventable errors:
    • Surgery on the wrong body part.
    • Surgery on wrong patient.
    • Wrong surgical procedure.
    • Unintended retention of a foreign object.
    • Patient death or serious disability associated with an air embolism.
    • Patient death or serious disability associated with incompatible blood or blood products.
    • Artificial insemination with the wrong donor sperm or egg.
    • Infant discharged to the wrong person.
    • Patient death or serious disability associated with failure to identify or treat hyperbilirubinemia in neonates.
    • Patient death or serious disability associated with a burn.
    • Patient death or serious disability associated with a medication error.
  • Oregon
    • Policy: Yes. Hospitals will not bill for 24 serious, preventable events outlined by the Oregon Patient Safety Commission:
    • Surgery on the wrong body part.
    • Surgery on the wrong patient.
    • Wrong surgery performed.
    • Object retained after surgery.
    • Death during or immediately after an operation of a healthy patient.
    • Patient death or serious injury associated with contaminated drugs, devices or biologics provided by the health care facility.
    • Patient death or serious injury associated with the use or function of a device used other than as intended.
    • Patient death or serious injury associated with an air embolism.
    • Infant discharged to the wrong person.
    • Patient death or serious injury associated with patient disappearance for more than four hours.
    • Patient suicide or attempted suicide resulting in serious injury while being cared for in a health care facility.
    • Patient death or serious injury associated with medication error.
    • Patient death associated with incompatible blood or blood products.
    • Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy.
    • Patient death or serious injury associated with hypoglycemia when the onset occurs in a health care facility.
    • Death or serious physical injury associated with failure to identify or treat hyperbilirubinimia in neonates.
    • Stage 3 or 4 pressure ulcers acquired after admission to health care facility.
    • Patient death or serious disability caused by spinal manipulative therapy.
    • Any perinatal death or serious physical injury unrelated to a congenital condition in an infant having a birth weight greater than 2500 grams.
    • Patient death or serious injury associated with electric shock in a health care facility.
    • Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances.
    • Patient death or serious physical injury associated with a burn while being cared for in a health care facility.
    • Patient death or serious physical injury associated with a fall in a health care facility.
    • Patient death or serious injury associated with the use of restraints or bedrails in a health care facility.
  • Pennsylvania
    • Policy: Yes. Won’t bill Medicaid for 18 errors:
    • Wrong surgical procedure on a patient
    • Patient death or serious disability from contaminated drugs, devices or biologics
    • Patient death or serious disability associated with use or function of a device other than as intended
    • Patient suicide or attempted suicide resulting in serious disability
    • Patient death or disability associated with medication administration error
    • Patient death from a fall while in the facility
    • Unexpected removal of organ
    • Unexpected amputation of limb
    • Death during or immediately after an operation in a normally healthy patient
    • Patient death or disability caused by incompatible ABO blood or products, two events
    • Maternal death or serious disability during labor or delivery of a low-risk pregnancy
    • Stage 3 or 4 pressure ulcers
    • Severe allergic reaction
    • Retention of a foreign object in a patient after surgery
    • Patient death or serious disability from a burn incurred from any source while in the healthcare facility
    • Patient death or disability associated with a medication error, two events.
  • Puerto Rico
    • Policy: No current policy.
  • Rhode Island
    • Policy: No current policy.
  • South Carolina
    • Policy: Yes. Won’t bill patients or insurers for 10 serious preventable events identified by the National Quality Forum, a nonprofit health care safety advocacy agency.:
    • Surgery performed on wrong body part.
    • Surgery performed on the wrong patient.
    • Wrong surgical procedure performed on patient.
    • Unintended retention of a foreign object in a patient after surgery or other procedure.
    • Patient death or serious disability associated with a medication error.
    • Patient death or serious disability associated with a hemolytic reaction due to the administration of incompatible blood or blood products.
    • Patient death or serious disability due to an air embolism.
    • Falls that result in death or serious disability.
    • Stage 3 or 4 pressure ulcers acquired after admission to a health care facility.
    • Patient death or serious disability associated with failure to identify and treat hyperbilirubinimia in neonates.
  • South Dakota
    • Policy: No current policy.
  • Tennessee
    • Policy: Yes. Will not charge patients or insurers for 11 preventable errors.
    • Surgery on the wrong body part.
    • Surgery on the wrong patient.
    • Wrong surgical procedure.
    • Unintended retention of a foreign object.
    • Patient death or serious disability associated with an air embolism.
    • Patient death or serious disability associated with a medication error.
    • Patient death or serious disability associated incompatible blood or blood products.
    • Artificial insemination with the wrong donor sperm or egg.
    • Infant discharged to the wrong person.
    • Patient death or serious disability associated with failure to identify and treat hyperbilirubinemia in neonates.
    • Patient death or serious disability associated with a burn from any source.
  • Texas
    • Policy: Yes. Will not charge patients or insurers for nine preventable errors.
    • Surgery performed on the wrong body part.
    • Surgery performed on the wrong patient.
    • Wrong surgery performed.
    • Patient death or disability associated with an air embolism.
    • Infant discharged to the wrong person.
    • Patient death or serious disability associated with incompatible blood or blood products.
    • Patient death or serious disability associated with failure to identify or treat hyperbilirubinemia in neonates duringthe first 28 days of life.
    • Artificial insemination with the wrong donor sperm or egg.
    • Patient death or serious disability associated with a burn from any source while being cared for in a facility.
  • Utah
    • Policy: Yes. Will not bill patients or insurers for 31 serious, preventable errors. That includes 26 of the 28 errors identified by the National Quality Forum, a nonprofit patient safety advocacy agency. The Utah code does not include NQF errors death or serious disability caused by hypoglycemia or artificial insemination with the wrong donor sperm or egg, but it adds five additional conditions:
    • Unanticipated death of a a full-term newborn.
    • Prolonged fluroscopy with cumulative dose greater than 1500 rad to a single field.
    • Radiotherapy to the wrong body region.
    • Radiotherapy greater than 25 percent above the precribed radiotherapy does.
    • Death or major permanent loss of function related to a health care-acquired infection.
  • Vermont
    • Policy: Yes. Won’t charge patients or insurers for eight serious, preventable errors identified by the National Quality Forum, a nonprofit health care safety advocacy agency:
    • Surgery on wrong body part.
    • Surgery on the wrong patient.
    • Wrong surgery performed.
    • Retention of foreign object in a patient after surgery.
    • Air embolism-associated injury.
    • Medication error injury.
    • Artificial insemination/wrong donor.
    • Incompatible blood-associated injury
  • Virginia
    • Policy: No current policy.
  • Washington
    • Policy: Yes. Hospitals, doctors and surgery centers won’t charge for 28 events identified by the National Quality Forum, a nonprofit health care safety advocacy agency.
  • West Virginia
    • Policy: Yes. Will not bill patients or their insurers for eight preventable errors.
    • Surgery performed on the wrong body part.
    • Surgery performed on the wrong patient.
    • Wrong surgery performed.
    • Unintended rentention of a foreign object after surgery.
    • Patient death or serious disability associated with a medication error.
    • Patient death or serious disability associated with incompatible blood or blood products.
    • Patient death or serious disability associated with an air embolism in a health care facility.
    • Artificial insemination with the wrong donor sperm or egg.
  • Wisconsin
    • Policy: Yes. Will not bill patients or insurers for nine preventable errors:
    • Surgery on the wrong body part.
    • Surgery on the wrong patient.
    • Wrong surgery performed.
    • Retention of a foreign object.
    • Air embolism-associated injury.
    • Infant discharged to the wrong person.
    • Artificial insemination with wrong donor sperm or egg.
    • Incompatible blood-associated injury.
    • Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances.
  • Wyoming
    • Policy: No current policy.