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Never Events List

Never EventsAs defined by the National Quality Forum and commonly agreed upon by health care providers,
the 28 never events are:

  • Artificial insemination with the wrong donor sperm or donor egg
  • Unintended retention of a foreign object in a patient after surgery or other procedure
  • Patient death or serious disability associated with patient elopement (disappearance)
  • Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
  • Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products
  • Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility
  • Patient death or serious disability associated with a fall while being cared for
    in a healthcare facility
  • Surgery performed on the wrong body part
  • Surgery performed on the wrong patient
  • Wrong surgical procedure performed on a patient
  • Intraoperative or immediately post-operative death in an ASA Class I patient
  • Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
  • Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
  • Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
  • Infant discharged to the wrong person
  • Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
  • Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility
  • Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
  • Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
  • Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
  • Patient death or serious disability due to spinal manipulative therapy
  • Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
  • Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
  • Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
  • Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
  • Abduction of a patient of any age
  • Sexual assault on a patient within or on the grounds of the healthcare facility
  • Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility

The Leapfrog Group offers four actions as industry standards following a never event:

  1. apologize to the patient
  2. report the event
  3. perform a root cause analysis
  4. waive costs directly related to the event

References

Retrieved from “https://en.wikipedia.org/wiki/Never_events
Categories: Medical terms
Hidden categories: Wikipedia references cleanup | All pages needing to be wikified | Wikify from November 2007