Never event

Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers. The term "Never Event" was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur.

Definition

The National Quality Forum (NQF) defines never events as errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a healthcare facility. Examples of never events include surgery performed on the wrong body part or on the wrong patient, wrong tissue or implant, foreign object left in a patient after surgery, and death or serious disability associated with a medication error.

Classification

The NQF initially identified 27 such events in 2002. As of 2011, the list has been expanded to 29 events grouped into six categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal.

Prevention

Prevention of never events involves a wide range of safety checks and balances, including the use of checklists, time outs to confirm surgical sites, and bar coding of medications. Despite these precautions, never events continue to occur, indicating a need for ongoing efforts to improve patient safety.

Reporting and Accountability

Many healthcare organizations have policies requiring that never events be reported to them, both internally and externally. Some states also require reporting of these events. The Centers for Medicare and Medicaid Services (CMS) has a policy of not paying for care related to never events, and many private insurers have adopted similar policies.

See Also

• Patient safety
• Medical error
• Healthcare quality

References

Never event Resources
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