As defined by the National Quality Forum and commonly agreed upon by health care providers, the 28 never events are:

• Artificial insemination with the wrong donor sperm or donor egg
• Unintended retention of a foreign object in a patient after surgery or other procedure
• Patient death or serious disability associated with patient elopement (disappearance)
• Patient death or serious disability 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 disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products
• Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility
• Patient death or serious disability associated with a fall while being cared for in a healthcare facility
• Surgery performed on the wrong body part
• Surgery performed on the wrong patient
• Wrong surgical procedure performed on a patient
• Intraoperative or immediately post-operative death in an ASA Class I patient
• Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
• Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
• Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
• Infant discharged to the wrong person
• Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
• 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 healthcare 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 healthcare facility
  Patient death or serious disability due to spinal manipulative therapy
• 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 healthcare facility
• Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
• Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
• Abduction of a patient of any age
• Sexual assault on a patient within or on the grounds of the healthcare facility
• 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 the healthcare facility

The Leapfrog Group offers four actions as industry standards following a never event:

1. apologize to the patient
2. report the event
3. perform a root cause analysis
4. waive costs directly related to the event.

References

Retrieved from "http://en.wikipedia.org/wiki/Never_events"
Categories: Medical terms
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