The Centers for Medicare and Medicaid Services (CMS) publishes a list of healthcare-acquired conditions (HACs), often referred to as “never events,” which are serious, preventable adverse events that should never occur in a healthcare setting. These conditions signify a failure in safety protocols and often result in significant patient harm, increased length of stay, and additional healthcare costs. At [Your Healthcare Organization Name] in Kisumu, we, like many responsible healthcare facilities globally, have implemented a multi-faceted and robust approach to manage and prevent these “never events” from happening. Our strategies combine proactive risk management, continuous quality improvement, and a strong culture of safety.

Here are some key actions and initiatives implemented to manage or prevent CMS-listed HACs:

1. Robust Infection Prevention and Control Programs

Healthcare-associated infections (HAIs) are a significant category of HACs, including Catheter-Associated Urinary Tract Infections (CAUTIs), Central Line-Associated Bloodstream Infections (CLABSIs), Surgical Site Infections (SSIs), and Clostridioides difficile (C. diff) infections. Our strategies include:

• Strict Hand Hygiene Protocols: This remains the cornerstone of infection prevention. We have implemented comprehensive hand hygiene programs with readily available alcohol-based hand rubs and soap/water stations throughout the facility. Regular audits and feedback on hand hygiene compliance are conducted, coupled with ongoing staff education.
• Bundles and Checklists: For high-risk procedures, we utilize evidence-based “bundles” – a set of best practices that, when implemented collectively, significantly reduce the risk of infection. Examples include:
  • CAUTI Bundle: Emphasizes appropriate catheter insertion, daily assessment for necessity, sterile technique, and prompt removal when no longer needed.
  • CLABSI Bundle: Focuses on maximal sterile barrier precautions during insertion, chlorhexidine skin antisepsis, avoiding femoral insertion sites, and daily review of line necessity with prompt removal.
  • SSI Prevention Bundles: Include pre-operative patient bathing, appropriate antibiotic prophylaxis timing, surgical site preparation, and strict sterile technique in the operating theatre.
• Environmental Cleaning and Disinfection: Meticulous cleaning and disinfection of patient rooms, medical equipment, and high-touch surfaces are crucial. Staff are trained on proper cleaning agents and techniques, especially for areas contaminated by C. diff.
• Antibiotic Stewardship Program: We have an active program to promote the judicious use of antibiotics. This includes reviewing antibiotic prescriptions, promoting de-escalation when cultures are available, and educating prescribers to reduce the development of antibiotic-resistant organisms like MRSA and C. diff.
• Surveillance and Feedback: Continuous surveillance of infection rates allows us to identify outbreaks quickly, track trends, and provide real-time data to specific units or departments for targeted interventions.

2. Comprehensive Falls Prevention Program

Patient falls are a major HAC, leading to fractures, head injuries, and other trauma. Our program includes:

• Universal Fall Risk Screening: All patients are screened for fall risk upon admission and regularly throughout their stay using validated tools (e.g., the Morse Fall Scale or local adaptations).
• Individualized Care Plans: For high-risk patients, individualized fall prevention plans are developed, which may include bed alarms, non-slip footwear, clear pathways, regular toileting, and involvement of family/caregivers.
• Environmental Safety Rounds: Regular checks are performed to ensure safe environments, including adequate lighting, call bells within reach, bed rails used appropriately, and clutter-free rooms.
• Post-Fall Huddles/Analysis: Any fall incident triggers an immediate huddle to understand contributing factors and implement immediate corrective actions. Serious falls lead to a thorough root cause analysis to identify systemic issues.
• Patient and Family Education: Educating patients and their families about fall risks and prevention strategies empowers them to actively participate in their safety.

3. Pressure Ulcer Prevention Initiatives

Stage III and IV pressure ulcers are preventable and represent a significant HAC. Our strategies align with evidence-based practices:

• Risk Assessment and Reassessment: Every patient is assessed for pressure ulcer risk using tools like the Braden Scale upon admission and regularly thereafter.
• Skin Assessment and Documentation: Nurses conduct meticulous skin assessments at least once per shift, paying close attention to bony prominences and areas of redness or skin breakdown. Accurate and timely documentation is crucial.
• Repositioning and Mobility: Individualized turning and repositioning schedules are implemented for immobile patients, often every two hours or more frequently. Early ambulation is encouraged for mobile patients.
• Pressure-Reducing Surfaces: We ensure access to and appropriate use of pressure-reducing mattresses, overlays, and cushions for at-risk patients.
• Nutritional Support: Collaboration with nutritionists ensures patients receive adequate nutrition and hydration to promote skin integrity and healing.
• Incontinence Management: Prompt and effective management of incontinence helps maintain skin integrity and prevents maceration.

4. Safe Surgical Practices

To prevent HACs like foreign object retained after surgery, wrong site/wrong patient/wrong procedure, and specific surgical site infections, we have implemented:

• Surgical Safety Checklist: Our operating rooms rigorously use the WHO Surgical Safety Checklist (or a locally adapted version) for every procedure. This includes ‘Sign In’, ‘Time Out’, and ‘Sign Out’ phases to ensure correct patient, site, procedure, and verification of equipment and sponges.
• Sterile Technique Adherence: Strict adherence to sterile technique during all surgical procedures and wound care.
• Team Communication and Huddles: Regular pre-operative and post-operative huddles ensure clear communication among the surgical team members, addressing potential risks and ensuring all concerns are voiced and addressed.