Credentialing & Privileging

Reader feedback: Never events in credentialing

Credentialing Resource Center Connection, July 30, 2009

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Never events is the term those in healthcare give to clinical events that should never happen, such as a wrong site surgery. However, the concept of a never event can apply to other areas of the hospital, including the medical staff services department. Last week we asked readers to tell us which credentialing errors they would deem never events. Here’s what you said:

“For those of us still in the paper credentialing world, a never event would be sending a credential file to off-site storage without having a complete scanned electronic copy as back-up in the event a file becomes irretrievable.”

“As a health care lawyer who frequently works with medical staff coordinators and reviews credentialing files, the occasional file that I see where there is a failure to query the NPDB for a reappointment or the failure to query the NPDB BEFORE the extension of temporary privileges still amazes me. Would seem that this should be a ‘never event’.”

“Physicians reappointment missed due to computer or human error, i.e., reappointment beyond two-year period.”

“I would definitely say making an erroneous report to the NPDB. At our facility, we have two CRNAs, both with the same first name. One last name is Reid and the other Reed.  Careful, careful!”

“Our CVO created Red Rules. Red Rules are standards that are akin to never events and could result in disciplinary action up to and including termination. Those are as follows:

  • Issuing privileges without the appropriate peer approval (chief of service, chief of staff, or hospital president)
  • Issue privileges or release a file to a client withoutverifying a valid license to practice
  • Failing to run a NPDB prior to issuing privileges or releasing a file to a client.



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