Never events

Never events are 28 occurrences on a list of inexcusable outcomes in a health care setting. The list was compiled by the National Quality Forum. They are defined as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability."[1]

Several states have enacted laws requiring the disclosure of never events at hospitals and various remunerative or punitive measures for such events. A recent Leapfrog Group Study[2] finds that roughly half of the 1,285 hospitals that responded to their survey waive fees for never events, and that hospitals that do waive fees are much more likely to have perfect scores on the Leapfrog Safe Practices Score survey.

List

As defined by the National Quality Forum[3] 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, and 4) waive costs directly related to the event.[4]