Untitled Document

"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 29 Serious Reportable Events - "Never events"
Surgical Events
	A. Invasive procedure on the WRONG SITE B. Invasive procedure on the WRONG PATIENT C. WRONG INVASIVE PROCEDURE D. UNINTENDED RETENTION OF FOREIGN OBJECT after an invasive procedure E. Intraoperative or immediate postoperative death of a ASA Class 1 patient.
Product or Device Event
	A. Patient death or serious injury associated with the use of contaminated drugs, devices or biologics provided by the healthcare setting 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 setting
Patient Protection Events
	A. Patient of any age discharged to an unauthorized person B. Patient death or serious disability associated with patient leaving the healthcare setting without authorization C. Patient suicide, attempted suicide, or serious self harm while being cared for in a healthcare setting
Care Management Events
	A. Patient death or serious injury associated with a medication error (e.g. wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration) B. Patient death or serious injury associated with the unsafe administration of blood products C. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting D. Death or serious injury of a neonate associated Labor and Delivery in a low risk pregnancy E. Patient death or serious injury associated with a fall while being cared for in a healthcare setting F. Stage 3, 4 and unstageable pressure ulcers acquired after admission to a healthcare setting G. Artificial insemination with the wrong donor sperm or wrong egg H. Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen I. Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results
Environmental Events
	A. Patient death or serious injury associated with an electric shock while being cared for in a healthcare setting 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 injury associated with a burn incurred from any source while being cared for in a healthcare setting D. Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a healthcare setting
Radiologic events
	Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area.
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 from a healthcare setting 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 setting D. Sexual assault (patient or staff) that occurs on the premises of a healthcare setting

"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.