What is a “Never Event” at a hospital?

In our last post we discussed serious medical malpractice incidents called “never events.” A Never Event is a medical mistake so negligent or reckless that it should never occur.

According to the U.S. Department of Health & Human Services, the term “never event” was first used in 2001 by Ken Kizer, MD. At the time, Dr. Kizer was the head of the National Quality Forum which used the term “Never Events” to refer to shocking medical negligence.

The term has evolved from its initial use but it is commonly understood to refer to a preventable adverse medical outcome that was unambiguous and serious, meaning that these events are both clearly identifiable and result in serious patient harm. Medicaid and Medicare programs now refuse to reimburse hospitals for expenses associated with some Never Events including wrong-site surgeries and preventable hospital injuries.

There are seven categories of Never Events identified by the NQF:

  1. Surgical events: including surgeries performed on the wrong patient, wrong body part surgeries, and objects left in a patient, such as sponges.
  2. Product or device events: including contaminated drugs and defective devices that harm patients.
  3. Patient protection events: including the improper discharge of incompetent patients, suicides during care, and injuries associated with a hospital’s failure to keep track of a patient.
  4. Care management events: including birth injuries during low-risk pregnancies, medication errors, loss of biological specimens, pressure ulcers, and patient harm associated with the failure of a hospital to communicate/follow up with test results.
  5. Environmental events: including electric shock at a hospital, harm caused by hospital restraints and bedrails, burns, and injuries associated with contaminated oxygen lines.
  6. Radiologic events: injuries associated with metal objects in the MRI area.
  7. Criminal events: including, kidnapping, assaults, rapes and care ordered by someone impersonating a healthcare provider.

Source: Agency for Healthcare Research and Quality, “Never Events: Background.”