Nosocomial infections are a highly monitored risk within health care facilities. “Medicare ceased payment for some hospital-acquired infections beginning October 1, 2008, following provisions in the Medicare Modernization Act of 2003 and the Deficit Reduction Act of 2005.” (Peasah et al., 2013) There is currently a list of fourteen (14) hospital acquired conditions designated by CMS as high cost, high volume, potential higher payment DRG, and preventable using evidence-based practice. (Centers for Medicare & Medicaid Services, 2013) Infection prevention and control are integral parts of any facility risk management plan. The fundamental first step in infection control is hand washing. It is drilled into nursing students’ brains during their program. It is often joked about as the answer to every test question…hand washing! However, this practice is a vital first line defense to cease the cross contamination between patients. “Practicing hand hygiene is a simple yet effective way to prevent infections. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult, if not impossible, to treat. On average, health care providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients has at least one health care-associated infection.” (Centers for Disease Control and Prevention, 2019) This simple act has been proven by the CDC as a highly effective preventative measure in the spread of disease.

Fall prevention is another high risk in health care facilities. Intake procedures include a fall risk assessment. Many facilities utilize a wrist band system that designates a patient at high risk for falls. “It is during the initial and reassessment procedures that risk factors associated with falls, allergies, DNR status or restricted extremity are identified or modified. Because this is an interdisciplinary process, it is important to identify who has responsibility for applying and removing color-coded bands, how this information is documented and how it is communicated.” (PATIENT SAFETY: COLOR BANDING Standardization and Implementation Manual, n.d.) The use of a designated color wrist band to identify a patient at risk for falls immediately enacts fall risk precautions designed to protect the patient’s safety and mitigate this risk. Staff education regarding the color coding, identification, and fall risk precautions to be implemented is as critical as the identification process. These actions have decreased fall injury greatly and assisted staff with rapid identification of this risk factor.

The Center for Medicare and Medicaid Services (CMS) publishes a list of health care-acquired conditions (HACs) that reasonably could have been prevented through the application of risk management strategies. What actions has your health care organization (or have health care organizations in general) implemented to manage or prevent these “never events” from happening within their health care facilities? Support your response with a minimum two peer-reviewed articles