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White Paper Calls for Re-evaluation of Pressure Ulcers as “Never Events”

white-paperAccording to a new white paper published by DM Systems Inc, the categorization of pressure ulcers by the Centers for Medicare and Medicaid Services (CMS) as “never events” should be re-evaluated. CMS reportedly defined “never events” in 2008 as issues that “cause serious injury or death to beneficiaries and result in unnecessary costs to Medicare and Medicaid due to the need to treat consequences of the errors.”

DM Systems Inc, Evanston, Ill, manufacturer of Heelift Glide and Heelift Suspension Boot, emphasizes that CMS included pressure ulcers in the list of medical issues classified as “never events.”

In its white paper, the company goes on to point out that many pressure ulcer cases result from issues that are beyond the direct control of the facility. Denis Drennan, MD, DM Systems founder and white paper author, explains that, “As we learn more about the role of microclimate, comorbidities, and end-of-life skin breakdown, the categorization of pressure ulcers as ‘never events’ increasingly calls for a re-evaluation of the established protocol.” In a recent news release, DM Systems Inc adds that in May 2013, CMS exhibited signs that it may already be in the process of re-evaluating “never events.”

In the CMS LTCH Quality Reporting Program Manual, slated to go into effect in 2014, CMS states the following, “Skin ulcers that develop in patients who have terminal illness or are at the end of life should be assessed and staged as pressure ulcers until it is determined that the ulcer is part of the dying process (also known as Kennedy [Terminal] ulcers). Kennedy Ulcers can develop from 6 weeks to 2 to 3 days before death… When an ulcer has been determined to be a Kennedy Ulcer, it should not be coded as a pressure ulcer.”

DM Systems points out that CMS had previously instructed facilities to code Kennedy Terminal Ulcers as pressure ulcers and therefore “never events.”

Read the DM Systems paper “Striving for Seldom, Hoping for Never: The Classification of Pressure Ulcers as ‘Never Events,’” by clicking here

[Source: DM Systems Inc]