Never events in the health care field refer to severe medical errors and extreme gaffes that should never happen when common sense precautions and standard preventative measures are employed by a healthcare provider.
Types of Never Events
There exists no consensus for what qualifies as a never event, though various organizations have created lists with their recommendations. The National Quality Forum (NQF) published a list of these types of events in 2002, which has been updated over time.
Surgical Errors
The NQF identifies the following as never events when associated with surgery or an invasive procedure:
- Operating on the wrong site on the patient
- Operating on the wrong patient
- Performing the wrong surgical procedure
- Leaving objects inside a patient unintentionally
Staff Errors
The NQF calls these issues “patient protection” never events when the consequences are death or serious disability for the patient:
- Releasing an infant/child to the wrong or unauthorized person
- “Losing” a patient in a healthcare facility
- Patient suicide, suicide attempts or other forms of self-harm in a healthcare setting
Medical Device Problems in a Healthcare Facility
The NQF deems the following as medical device never events when the device is provided by the healthcare facility and the error leads to death or severe disability of the patient:
- Biologic, drug or device contamination used on the patient
- “Off-prescription” use/function of a device during patient care
- Intravascular air embolism
Hospital Acquired Conditions (HACs) and Environmental Events
The NQF identifies these care management issues as never events when the problems/conditions occur after admittance to a healthcare facility and the result is death, serious injury, or disability:
- Medication errors, such as incorrect dosage, wrong patient, wrong drug, inaccurate time or method of drug administration, wrong preparation and wrong rate
- Blood/hemolytic reaction due to administration of incompatible blood products
- Low-risk pregnancy that ends in maternal or neonatal death or disability during labor & delivery
- Hypoglycemia leading to death or disability
- Neonatal death or disability due to undiagnosed/untreated hyperbilirubinemia
- Stage 3 or 4 pressure ulcers
- Loss of a biological specimen that cannot be replaced/retrieved
- Death or disability related to spinal manipulative therapy
- Serious falls in a healthcare setting
- Electric shock during the patient care process
- Use of bedrails and/or physical restraints that cause death or disability
- Burns suffered by patient or staff during the patient care process
- Communication errors or follow-up failures regarding radiology, pathology, or other laboratory results
- Artificial insemination with the wrong donor egg or sperm
- Metallic objects in the MRI area
Additional Never Events
The Centers for Medicare & Medicaid Services (CMS) has a much shorter list. Most overlap with the NQF, but it also includes the following situations as never events:
- Blood clots developed after hip-replacement and knee-replacement surgeries
- Elective procedure surgical site infections, such as bariatric surgery, bypass surgery, and some orthopedic procedures
- Complications associated with poorly controlled glucose levels
- Infections from vascular-catheters
- Urinary Tract Infection (UTI) associated with catheter use
- Falls and other trauma, such as crushing injuries, burns, electric shock, dislocations, fractures, and intracranial injuries
Never events are gross errors that should never occur. If you or someone you love has experienced a preventable adverse event in a medical setting that caused damage and harm, contact the Reinartz Law Firm. Our experienced medical malpractice team can review your situation and explain your rights and options.
Statistical Sources:
http://www.healthleadersmedia.com/quality/never-event-frequency-troubling-standards-lacking
