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.”

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