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Never Events
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Background

The term "Never Event" was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The NQF initially defined 27 such events in 2002. The list has been revised since then, most recently in 2011, and now consists of 29 events grouped into 6 categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal.

Sentinel events most frequently reported* to the Joint Commission. Wrong-site surgery: 867 reports (13.5%), suicide: 770 reports (12%), op/post-op complications: 710 reports (11%), delay in treatment: 536 reports (8.3%), medication error: 526 reports (8.2%), patient fall: 406 reports (6.3%). (*6428 total reports as of September 30, 2009)

Source: Sentinel Event Statistics. September 30, 2009. The Joint Commission Web site.

Distribution of the 312

Source: Adverse Health Events in Minnesota. Fifth Annual Public Report. St. Paul, MN: Minnesota Department of Health; January 2009. Available at: http://www.health.state.mn.us/patientsafety/publications/
consumerguide.pdf
. Accessed December 30, 2009.

Table. Never Events, 2011

The National Quality Forum's Health Care "Never Events" (2011 Revision)

Surgical events

Surgery or other invasive procedure performed on the wrong body part

Surgery or other invasive procedure performed on the wrong patient

Wrong surgical or other invasive procedure performed on a patient

Unintended retention of a foreign object in a patient after surgery or other procedure

Intraoperative or immediately postoperative/postprocedure death in an American Society of Anesthesiologists Class I patient

Product or device events

Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the health care setting

Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used for functions other than as intended

Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care setting

Patient protection events

Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person

Patient death or serious disability associated with patient elopement (disappearance)

Patient suicide, attempted suicide, or self-harm resulting in serious disability, while being cared for in a health care facility

Care management events

Patient death or serious injury 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 injury associated with unsafe administration of blood products

Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a health care setting

Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy

Artificial insemination with the wrong donor sperm or wrong egg

Patient death or serious injury associated with a fall while being cared for in a health care setting

Any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a health care facility

Patient death or serious disability resulting from the irretrievable loss of an irreplaceable biological specimen

Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results

Environmental events

Patient or staff death or serious disability associated with an electric shock in the course of a patient care process in a health care setting

Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances

Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a health care setting

Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a health care setting

Radiologic events

Death or serious injury of a patient or staff associated with introduction of a metallic object into the MRI area

Criminal events

Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider

Abduction of a patient/resident of any age

Sexual abuse/assault on a patient within or on the grounds of a health care setting

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 a health care setting

(Reprinted with permission from the National Quality Forum.)

Most Never Events are very rare. For example, a 2006 study estimated that a typical hospital might experience a case of wrong-site surgery once every 5 to 10 years. However, when Never Events occur, they are devastating to patients—71% of events reported to the Joint Commission over the past 12 years were fatal—and may indicate a fundamental safety problem within an organization.

The Joint Commission has recommended that hospitals report "sentinel events" since 1995. Sentinel events are defined as "an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof." The NQF's Never Events are also considered sentinel events by the Joint Commission. The Joint Commission mandates performance of a root cause analysis after a sentinel event. The Leapfrog Group recommends that in addition to an RCA, organizations should disclose the error and apologize to the patient, report the event, and waive all costs associated with the event.

Current Context

Because Never Events are devastating and preventable, health care organizations are under increasing pressure to eliminate them completely. The Centers for Medicare and Medicaid Services (CMS) announced in August 2007 that Medicare would no longer pay for additional costs associated with many preventable errors, including those considered Never Events. Since then, many states and private insurers have adopted similar policies. Since February 2009, CMS has not paid for any costs associated with wrong-site surgeries.

Never Events are also being publicly reported, with the goal of increasing accountability and improving the quality of care. Since the NQF disseminated its original Never Events list in 2002, 11 states have mandated reporting of these incidents whenever they occur, and an additional 16 states mandate reporting of serious adverse events (including many of the NQF Never Events). Health care facilities are accountable for correcting systematic problems that contributed to the event, with some states (such as Minnesota) mandating performance of a root cause analysis and reporting its results.

 
What's New in Never Events on AHRQ PSNet
COMMENTARY
Redesigning surgical decision making for high-risk patients.
Glance LG, Osler TM, Neuman MD. N Engl J Med. 2014;370:1379-1381.
STUDY
Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample.
Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Diagnosis. 2014 Apr 5; [Epub ahead of print].
STUDY
Detection of adverse events in an acute geriatric hospital over a 6-year period using the Global Trigger Tool.
Suarez C, Menendez MD, Alonso J, Castaño N, Alonso M, Vazquez F. J Am Geriatr Soc. 2014 Apr 2; [Epub ahead of print].
BOOK/REPORT
Hospital Survey on Patient Safety Culture: 2014 User Comparative Database Report.
Sorra J, Famolaro T, Yount ND, Smith SA, Wilson S, Liu H. Rockville, MD: Agency for Healthcare Research and Quality; March 2014. AHRQ Publication No. 14-0019-EF.
STUDY
Association of note quality and quality of care: a cross-sectional study.
Edwards ST, Neri PM, Volk LA, Schiff GD, Bates DW. BMJ Qual Saf. 2014;23:406-413.
NEWSPAPER/MAGAZINE ARTICLE
Is your hospital really as safe as you think? Our updated hospital safety score can help you find out.
Consum Rep. March 27, 2014; [Epub ahead of print].
STUDY
Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety.
McFadden KL, Stock GN, Gowen CR III. Health Care Manage Rev. 2014 Feb 21; [Epub ahead of print].
 
Editor's Picks for Never Events
From AHRQ WebM&M
Advancing Patient Safety through State Reporting Systems.
Jill Rosenthal, MPH. AHRQ WebM&M [serial online]. June 2007
The Other Side.
Charles Vincent, PhD. AHRQ WebM&M [serial online]. October 2003
 
From AHRQ PSNet
JOURNAL ARTICLE
Incidence, patterns, and prevention of wrong-site surgery. Classic icon
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.
Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.
Michaels RK, Makary MA, Dahab Y, et al. Ann Surg. 2007;245:526-532.
Inpatient suicide: preventing a common sentinel event.
Tishler CL, Reiss NS. Gen Hosp Psychiatry. 2009;31:103-109.
Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand. Classic icon
Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.
Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Classic icon
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
Medicare's policy not to pay for treating hospital-acquired conditions: the impact. Classic icon
McNair PD, Luft HS, Bindman AB. Health Aff (Millwood). 2009;28:1485-1493.
BOOK/REPORT
Serious Reportable Events in Healthcare—2011 Update. Classic icon
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
What Every Health Care Organization Should Know about Sentinel Events.
McKee J, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2005. ISBN: 0866889116.
Consumer Guide to Adverse Health Events.
St. Paul, MN: Minnesota Department of Health; January 2009.
NEWSPAPER/MAGAZINE ARTICLE
Medicare says it won't cover hospital errors.
Pear R. New York Times. August 19, 2007.
TOOLS/TOOLKIT
Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
WEB RESOURCE
Sentinel Event. Classic icon
The Joint Commission.
 
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Last Updated: October 2012