The National Quality Forum (NQF) promotes patient safety to prevent adverse events in health care; in 2002 the NQF developed and endorsed a set of 27 serious reportable events. These negative patient complications are ones that should never have happened and have become known as never events. Complications such as falls, pressure ulcers, and hospital-acquired infections are designated as never events because they generally are preventable and the consequences can lead to serious harm, including death. Research supports that poor or absent communication can lead to patient harm or death. A growing body of literature addresses an almost epidemic rate of lateral violence in the workplace (ie, violence among health care staff or between patients and health care staff that includes sexual harassment and bullying) in which nothing is reported or done to alleviate the problem.4,5...

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