QualiPedia: Never Events

Inexcusable mistakes in health care

Published: Tuesday, November 9, 2010 - 08:45

The term “never events” refers to particularly shocking medical errors that should never occur (e.g., wrong-site, wrong-patient, wrong-procedure surgeries). There are other terms used in official capacities for such errors, but none have captured the nation’s attention or perhaps done more toward improving patient safety as never events.

Bringing never events to the public eye all began when the Institute of Medicine published To Err Is Human: Building a Safer Health System (National Academies Press, 2000) on the quality of healthcare in the United States. Shocking medical mistakes were exposed but with recommendations on how to learn from these mistakes. It was recommended that a nationwide mandatory reporting system should be established with “a focus on detection of errors that result in serious patient harm or death (i.e., preventable adverse events). Adequate attention and resources must be devoted to analyzing reports and taking appropriate follow-up action to hold healthcare organizations accountable. The results of analyses of individual reports should be made available to the public.”

Prior to the year 2000, only a few states required reporting healthcare errors, and no standardized list of reportable events existed. In 2002, the National Quality Forum (NQF), a nonprofit organization established to improve the quality of U.S. healthcare, created and endorsed a list of 27 serious reportable events that could be used as the backbone for states’ incident-reporting systems. Commonly known as the Never Events List, the “Serious Reportable Events in Healthcare: A Consensus Report” was created for “identifying an unambiguous, standardized list of serious reportable events that could form a basis for a national mandatory reporting system that would lead to substantial improvements in patient safety.”

To further reduce the risk of harm to patients, NQF published a companion report “Safe Practices for Better Healthcare” to identify 30 safe practices that should be universally utilized in applicable clinical care settings.

Revised in 2006, “Serious Reportable Events in Healthcare” included updated specifications, an additional event regarding artificial insemination with the wrong donor sperm or wrong egg, and a summary of the progress made in implementing a serious reportable event reporting system, as well as guidance on implementing such a system. 

The following are 28 events that NQF listed and described as being “serious, largely preventable, and of concern to healthcare providers, consumers, and all stakeholders” in its consensus report “Serious Reportable Events in Healthcare.”

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 ASA Class I patient

Product or device events

• 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

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 healthcare facility

Care management events

• 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
• Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare 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 (bed sores) acquired after admission to a healthcare facility
• Patient death or serious disability due to spinal manipulative therapy
• Artificial insemination with the wrong donor sperm or wrong egg

Environmental events

• Patient death or serious disability associated with an electric shock while being cared for in a healthcare 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 healthcare facility
• Patient death or serious disability associated with a fall while being cared for in a healthcare facility
• Patient death or serious disability associated with the use of restraints or bed rails while being cared for in a healthcare facility

Criminal events

• 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 a 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 a healthcare facility

The majority of state reporting systems now require facilities to conduct root cause analyses and submit information about root causes and corrective action plans with their reports.

Sources

To Err Is Human: Building a Safer Health System, by the Institute of Medicine (National Academies Press, 2000)
“Safe Practices for Better Healthcare” (National Quality Forum, 2003)
“Serious Reportable Events in Healthcare–2006 Update” (National Quality Forum, 2006)
“Advancing Patient Safety through State Reporting Systems” by Jill Rosenthal

About The Author

Laurel Thoennes @ Quality Digest

Laurel Thoennes is an editor at Quality Digest. She has worked in the media industry for 33 years at newspapers, magazines, and UC Davis—the past 25 years with Quality Digest.