The hospital is increasingly considered to be a dangerous place. Studies cite that as many as 400,000 hospitalized patients a year are exposed to some type of preventable harm (James 2013) with an estimated 40,000 to 200,000 yearly hospital deaths considered preventable (Kavanagh 2017; Gray 2021). These preventable harms are estimated to cost the United States upwards of $20 billion per year (Van Den Bos 2011). 

Various tactics have been utilized by federal governing bodies to reduce patient harm. In 2008, the Centers for Medicare & Medicaid Services identified a list of “never events” for which CMS stopped reimbursing hospitals for the costs incurred due to these hospital acquired conditions (Brown 2009). By halting payments for services if those services resulted in harm, they reasoned that this would incentivize hospitals to systematically reduce those never events. Currently, strategies of proactively reforming payment and coverage policies to discourage payment are the cornerstone of CMS’s commitment to the goal of zero harm, and the list of “never events” has expanded in the ensuing years (CMS National Quality Strategy Nov 2024). Likewise, The Joint Commission requires the hospitals they accredit to investigate all reported sentinel events resulting in death or serious injury including wrong-site procedures, retained foreign body after surgery, and severe morbidity or mortality in neonates or mothers through comprehensive systematic analysis (Joint Commission International 2025)). Failure to do so can lead to removal of the hospital’s accreditation.

In response to the threat of withholding reimbursements, and the reality that publicly released data may affect their patient base, hospitals have used a combination of tactics to prevent hospital-acquired conditions with varying success (Ranji 2007).  Strategies include provider reminder systems, auditing of performance data, provider education, patient education, and organizational change. The method of withholding reimbursement by CMS may initially seem like a logical step to incentivize hospitals for better patient care and outcomes, but what if these conditions are not entirely preventable? Is it right to financially punish the hospital? What if the financial ramifications trickle down as hospital systems incentivize individual practitioners to meet metrics? (Hsu 202; Shittu 2021)

The definition of “preventable harm” varies depending on the source and may explain the widely disparate estimates of incidence. Preventable harm also encompasses diagnostic errors, surgical and medication errors, hospital-acquired infections (HAIs), deep tissue injuries, and patient falls. In reality, pressure ulcers and HAIs make up the bulk of the preventable harms and are much less dramatic than the “never events” initially targeted for restricted payment.

It is not clear that all HAIs are preventable (Brown 2009).  In the intensive care unit, patients often require central lines or urinary catheterization due to critical illness and may be at higher risk for developing infections because of an immunosuppressed status. Based on the repercussions of withholding reimbursement and accreditations, providers may be forced to remove catheters before their clinical use is complete, leading to other complications that may not be tracked by CMS, such as peripheral IV infiltration, PICC-associated venous thrombosis, or urinary retention causing kidney injury. Further, definitions of CLABSIs and CAUTIs are imperfect – a bloodstream infection in a critically ill patient too ill to move for further imaging may be attributed to their central line rather than a bowel perforation if no radiographic evidence can be obtained, and a neurologically-ill patient with a colonized bladder may meet criteria for a CAUTI because of central-mediated fevers even if there is no evidence of infection on the urinalysis.  Given the fear of penalty, teams may initiate empiric antibiotic treatment without sending cultures if an infection is suspected, resulting in antibiotic resistance and exposure to unnecessary toxicity of overly broad antimicrobials.

Not all pressure injuries appear to be avoidable either (Schmitt 2017), and the risk to neurocritically ill patients, who may have prolonged periods of immobility and poor nutritional status, is particularly high. The higher likelihood of the sicker and chronically ill patients to negatively impact a hospital’s finances may incentivize nursing staff to spend crucial first moments of evaluation to identify the skin integrity/discontinuity that they arrived with instead of rapidly transporting them to the interventional suite or operating room. Worse, a hospital may avoid taking care of these patients at all.

An excessive focus on these metrics may also contribute to moral distress of hospital staff.  One survey of critical care providers associated with the Society of Critical Care Medicine revealed that 35% felt CLABSI and CAUTI metrics pose ethical dilemmas in clinical practice and 7% and 17% of providers would avoid sending blood cultures and urine cultures, respectively, in a septic patient with a central line or foley catheter (Nelson 2024). Additionally, morale may drop with a disproportionate focus on metrics. For example, there were well-documented surges in CLABSI and CAUTI rates during the COVID-19 outbreak that were at least partially attributable to increased patient acuity, utilization of catheters, and decreased resources (Kang 2023, Ford 2024, Hyte 2024). The increased demands on hospital staff compounded with administrative reprimand could negatively affect healthcare workers who were already spread thin.

To be clear, measures to reduce patient harm are laudable, and health care personnel and hospital leadership should continue to advocate for and implement evidence-based quality improvements.  But when imperfect metrics are the measuring stick, when concerns about accreditation, finances, and public opinion drive hospital policy and health care practice, these techniques may worsen the quality care that patients receive.

The consequences of these incentives potentially negatively interfere with standard practices, including using appropriate catheters, drawing of cultures, or discouraging care for the sickest patients, and should be carefully considered by government agencies. Alternatives to punitive measures, such as audits and surveillance with tailored feedback, are practiced in other countries and have been shown to be effective in reducing rates of HAIs (Richards 2017, Chow 2021, Adawee 2023) Alternative definitions of CLABSI and CAUTI may also be helpful to acknowledge the true complexity of a patient. However, perhaps the most radical change of all would be acknowledging that CLABSIs and CAUTIs may not be “never events” but may instead be natural complications of providing critical care to the sickest patients.