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"Never Events"

"...events that should never happen in any clinical care setting,
but unfortunately do and should be publicly reported when they occur" - (NQF, 2002)

The National Quality Forum (NQF) has made a significant contribution to patient safety. Through a consensus building process involving a broad spectrum of healthcare stakeholders, the NQF has created a standardized list of serious reportable events (SREs). The list contains 28 preventable adverse events that can be used to form a state-based or national reporting system. In fact, the U.S. government and many states are adopting some or all of these events as mandatory reportable events.

National Quality Forum 28 Serious Reportable Events - "Never events"
Surgical Events
	A. Surgery on the wrong body part B. Surgery performed on the wrong patient C. Wrong surgical procedure performed on a patient D. Unintended retention of a foreign object in a patient after surgery or other procedure E. Intraoperative or immediate postoperative death in an ASA Class 1 patient.
Product or Device Event
	A. Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility B. 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 C. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
Patient Protection Events
	A. Infant discharged to the wrong person B. Patient death or serious disability associated with patient leaving the facility without permission C. Patient suicide, or attempted suicide, resulting in serious disability while being cared for in a healthcare facility
Care Management Events
	A. 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) B. Patient death or serious disability associated with a hemolytic reaction (abnormal breakdown of red blood cells) due to the administration of ABO/HLA – incompatible blood or blood products C. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility D. Death or serious disability associated with failure to identify and treat hyperbilirubinemia (condition where there is a high amount of bilirubin in the blood) in newborns E. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility F. Patient death or serious disability due to spinal manipulative therapy G. Artificial insemination with the wrong donor sperm or wrong egg
Environmental Events
	A. Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility B. 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 C. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility D. Patient death or serious disability associated with a fall while being cared for in a healthcare facility E. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
Criminal Events
	A. Any instance of care ordered or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider B. Abduction of a patient of any age C. Death or significant injury of a patient or staff member resulting form a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility D. Sexual assault (patient or staff) that occurs on the premises of a healthcare facility

"Never events" are without question the most catastrophic of all healthcare safety failures. They often receive extraordinary attention and rightfully so. Acknowledging the seriousness of the error and presenting a meaningful plan to avoid replication is often the most effective way to re-establish public trust in the healthcare system.

The occurrence of a "never event" does not indicate a lack of commitment to patient safety. The true measure of an organization's safety commitment is its response to each "near-miss." Every near-miss offers your organization the opportunity to learn, improve and prevent potential "never events." Protect yourself, your patients and your organization by completing an "incident report" when the slightest harm occurs or when any safety risk is identified.

Click here to visit the National Quality Forum web site.