Doctor Ken Kizer, the former CEO of the National Quality Forum (NQF), coined the term “Never Event” in 2001 to categorize reference to particularly shocking medical errors that should never occur. The seminal example would be performing an unnecessary surgery on the patient’s right arm when that procedure was scheduled to treat a problem on the left arm. The list of “never events” has expanded over time to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The most recent NQF list of these events came out in 2011 and now consists of 29 events grouped into 6 categories.
Table. The NQF’’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 healthcare 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 healthcare 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 healthcare 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 healthcare setting
– Any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a healthcare 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 healthcare 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 healthcare setting
– Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a healthcare 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 healthcare provider
– Abduction of a patient/resident of any age
– Sexual abuse/assault on a patient within or on the grounds of a healthcare 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
While many of the above events are incredibly rare, others are not. MCR has been involved in many cases involving stage III or higher pressure ulcers, foreign objects like sponges left in during surgery, and serious injury from burns suffered in surgery. Defendant healthcare providers in these situations, incredibly, still defend on the basis that their conduct did not fall below the standard of care.
Never Events are devastating and preventable, and healthcare 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 (but, not Arizona) and private insurers have adopted similar policies.
MCR’s personal injury litigators understand “never events,” and have the data to have this evidence admitted for a jury to consider if a healthcare provider denies liability in a “never event” circumstance.
