A Focus on ‘Never Happen Events’

The Hershel “Woody” Williams Veterans Administration Medical Center is on a mission to achieve high reliability in all the processes that support the provision of top-quality care. The medical center began a journey in March 2020 to focus on what it calls “never happen events”—incidents that could occur in its clinical and administrative processes and cause patient harm—as a strategy to get to zero instances of preventable harm.

What Is a Never Happen Event?
Hershel “Woody” Williams VA Medical Center took the traditional “never event” phrase, which is ubiquitous in direct care settings, and expanded it to never happen events, which includes all services (departments) and all activities connected to the care of its veteran patients. The goal was to increase overall safety and high reliability by reducing the chances of human error that most often lead to a never happen event. 

All departments were asked to identify critical, preventable events associated with their processes. It was important to help staff distinguish between never happen events—which are single events—and continuous process improvement, which is ongoing.

The work being done on never happen events is not something that is new in healthcare. Those in the field have been working on patient safety alerts, patient safety goals and other initiatives aimed at eliminating those events that all would agree can never happen. Having deliberate work under the premise of preventing never happen events raises the level of awareness, potentially changes how the medical center approaches these incidents and elevates the organization’s thought process from that of just a goal or other initiative. Overtly stating these are “never happen events” sends a clear message.

Identifying the Critical 7
After each department identified its own never happen events, the medical center’s established High Reliability Organization Workgroup provided education and support to help departments refine those ideas. Seven priority never happen events were selected:

1. Patient injury, harm or death resulting from failure to act on critical results (e.g., vital signs, lab, and/or diagnostic study results).
2. Patient, visitor, employee or volunteer injury, harm or death resulting from procedural errors linked to insufficient and/or documented competency on the part of any employee.
3. Abuse or assault of any veteran under the medical center’s care.
4. Adverse patient event due to unrecognized hypoglycemia.
5. Patient harm or death from a failure to obtain immediate assistance for a patient expressing suicidal thoughts or behaviors.
6. An employee does not get paid.
7. Adverse event or near miss due to moderate sedation administration.

For the seven issues identified, workgroups were established, and preventive actions were initiated. Steps for preventing the priority never events and improving processes to assist with prevention are guided by one or more (or a combination of two are more) of the following frameworks: Lean, change management, root cause analysis, and Healthcare Failure Mode and Effects Analysis.

Early Results, Recognition and Spread
Monitoring the medical center’s never happen events work is ongoing. Staff employ high reliability organization principles in the course of this work. For example, one HRO principle, sensitivity to operations, is demonstrated by getting front-line staff involved in determining current processes, including strengths and weaknesses. In eliminating events involving employees not being paid, for example, front-line payroll and human resources staff were involved in defining the process.

A highlight of this never happen event work has been the significant safety enhancements that have occurred to reduce the likelihood of an adverse event related to moderate sedation administration. These include having certified registered nurse anesthetists in the gastrointestinal suite, reduction in the use of benzodiazepines and opioids, and improved documentation related to medications given. As a result of these efforts, a more positive patient experience has been achieved with faster recovery times and a more comfortable procedure. This undertaking has been recognized with the Veterans Health Administration’s HeRO Award, the highest level of high reliability organization recognition available within the administration.

The sharing of this type of strong high reliability organization practice throughout the VA system is facilitated by leader coaches, who support medical center HRO implementation. They work closely with their assigned VAs to set priorities, develop action plans and monitor effectiveness. The hallmarks of the leader coach engagement are the sharing of resources and strong practices while facilitating change within the medical centers.

Lessons Learned
The medical center is still in the beginning stages of its never happen events effort; however, there have already been lessons learned. The following two key lessons are also helpful considerations for other healthcare organizations that are on their own never happen events journeys.

The identification of a never happen event versus the work done under the umbrella of continuous process improvement needs clarification. The difference can be a little confusing at times, and some issues may fall squarely in a gray area.

For example, is a patient suicide considered a never happen event or continuous process improvement? All who are working in healthcare, and especially in veterans’ healthcare, agree that any suicide is unacceptable and should be considered a never happen event. Suicide prevention strategies have been in place for some time (e.g., depression screening, suicide screening, intensive case management, crisis lines) and could certainly be considered continuous process improvement. The point in using this example is to suggest there could be parallel efforts between continuous process improvement and never happen events, as it is the desired result that should drive the effort. 

Work on dissemination throughout the organization needs improvement. Front-line staff should be able to identify both their departments’ and the organization’s never happen events efforts. This can be accomplished during routine staff meetings or team huddles.

One of the most important results of the never happen events effort is the overall increase in attention to detail that has resulted from staff doing all the work to provide safe and reliable care for veterans. Attitude is contagious, and an attitude that there are some events that are unacceptable and just cannot happen will spread. An intense organizational focus not only prevents events that shouldn’t happen but also helps improve overall performance expectations and the standard of care. 

J. Brian Nimmo, FACHE, is director, Hershel “Woody” Williams VA Medical Center, Huntington, W.Va. (Brian.Nimmo1@va.gov). Mary-Ellen Piche, CPHQ, LFACHE, is a consultant based in Albany, N.Y. (picheme@gmail.com).