Never Events

Background

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. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The NQF initially defined 27 such events in 2002 and revised and expanded the list in 2006. The list is grouped into six categorical events: surgical, product or device, patient protection, care management, environmental, and criminal.

Most Never Events are very rare. For example, a 2006 study estimated that a typical hospital might experience a case of wrong-site surgery once every 5 to 10 years. However, when Never Events occur, they are devastating to patients — 71% of events reported to the Joint Commission over the past 12 years were fatal — and may indicate a fundamental safety problem within an organization.

The Joint Commission has required that hospitals report "sentinel events" since 1995. Sentinel events are defined as "an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof." The NQF's Never Events are also considered sentinel events by the Joint Commission.

Current Context

Because Never Events are devastating and preventable, health care organizations are under increasing pressure to eliminate them completely. In August 2007, the Centers for Medicare and Medicaid Services (CMS) announced that Medicare would no longer pay for the treatment of many preventable errors, including those considered Never Events.

The growing trend of public reporting on health care quality has also focused on reporting Never Events as a means of increasing accountability and potentially improving the quality of care. Since the NQF disseminated its original Never Events list in 2002, 11 states have mandated reporting of these incidents whenever they occur, and an additional 16 states mandate reporting of serious adverse events (including many of the NQF Never Events). Health care facilities are accountable for correcting systematic problems that contributed to the event, with some states (such as Minnesota) mandating performance of a root cause analysis and reporting its results.

The National Quality Forum's Health Care "Never Events" (2006)

• 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 deatn in an ASA Class I patient
  • Artificial insemination with the wrong sperm or donor egg
• Product or Device Events
  • Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the health care facility
  • Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used for functions orhter than as intended
  • Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a health care 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 health care facility
• Care Management Events
  • Patient death or serious disability associated with a medication error (eg 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 health care facility
  • Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility
  • Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
  • Stage 3 or 4 pressure ulcers acquired after admission to a health care facility
  • Patient death or serious disability due to spinal manipulative therapy
• Environmental Events
  • Patient death or serious disability associated with an electric shock or electrical cardioversion while being cared for in a health care 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 health care facility
  • Patient death or serious disability associated with a fall while being cared for in a health care facility
  • Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility
• Criminal Events
  • Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider
  • Abduction of a patient of any age
  • Sexual assault on a patient within or on the grounds of the health care facility
  • Death or significant injury of a patient or staff member resulting from a physical assault (ie, battery) that occurs within or on the grounds of the health care facility

Ref: http://www.psnet.ahrq.gov/primer.aspx?primerID=3