Two Mayo Clinic employees, including AASM past president Timothy Morgenthaler, MD, explain in Harvard Business Review what the Mayo Clinic does to prevent “never events” (preventable harmful events).

For example, some years ago we noted that there was a growing prevalence in problems with smooth and safe direct admissions and transfers into our hospital. Due to inadequate information, patients would occasionally arrive too ill to be cared for in the area where they were first bedded and would soon need to be transferred to an area that could provide a higher level of care. Consequently, we developed a much better system that ensures that patients will receive safer transport and will arrive in the area most appropriate for their needs.