Table. Never Events, 2006

The National Quality Forum’s Health Care "Never Events" (2006)

Surgical events

Surgery performed on the wrong body part

Surgery performed on the wrong patient

Wrong surgical procedure performed on a patient

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

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

Artificial insemination with the wrong sperm or donor egg

Product or device events

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

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

Patient protection events

Infant discharged to the wrong person

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

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

Care management events

Patient death or serious disability associated with a medication error (eg, 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

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 health care 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 health care facility

Patient death or serious disability due to spinal manipulative therapy

Environmental events

Patient death or serious disability associated with an electric shock or electrical cardioversion while being cared for in a health care facility

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 health care facility

Patient death or serious disability associated with a fall while being cared for in a health care facility

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

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 of any age

Sexual assault on a patient within or on the grounds of the health care facility

Death or significant injury of a patient or staff member resulting from a physical assault (ie, battery) that occurs within or on the grounds of the health care facility