Editorial comment

摘要

Are these events always preventable? The rinding that high-volume hospitals have significantly lower odds suggests these events can be prevented. The 2 most common events identified by the authors, pressure ulcers and vascular catheter-associated infections, have established processes of care to help prevent the development of the complications. Focusing resources on preventing such complications among the highest risk patients would benefit both patients and hospitals. The CMS will not change their reimbursement policy; the evidence of the adverse effects of the "never events," as outlined in this report is too strong. Instead, physicians should work as partners with their hospitals to ensure the best care of their high-risk patients and ensure that the processes of care in their hospital are up to the highest standards.