What are Never Events?

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  • Written By: Mary McMahon
  • Edited By: Nancy Fann-Im
  • Last Modified Date: 02 February 2020
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Never events are problems that should not ever happen in a hospital because they represent significant failures of care. They include things like sexual assault of patients, accidentally releasing a baby to the wrong person, or performing surgery on an incorrect site. If a hospital experiences one of the outcomes on a never events list, it may need to report it and can have other obligations such as undergoing a mandatory review to find out why it happened and prevent an incident in the future.

The concept of never events was the result of pushes for health care reform in the early 2000s, when advocates recommended identifying a list of inexcusable outcomes and events in hospital settings to better track performance at medical facilities. The initial list had 27 items, and people periodically revise it to reflect changing attitudes about hospital care with an ever-growing number of items. When such events occur at a hospital, the response may involve apologizing to the patient, waiving any fees for treatment associated with the bad outcome, and enacting better controls to prevent such situations from recurring.


Usually, never events are situations where patients clearly suffer as a result of neglect or inattentiveness. If the life or health of a patient is threatened because someone fails to observe basic procedures, or a patient experiences psychological distress, as might occur if a hospital implanted the wrong embryo in a patient, there's a chance it may be considered a never event. For hospitals, such events create considerable legal liability because if the patient takes the matter to court, the hospital will probably lose. Hospitals often try to reach a settlement to keep the situation out of the news.

Hospital rankings depend on their performance, and a history of reporting never events can push a hospital further down when ratings agencies evaluate it. This can result in negative publicity for the hospital, leading to reduced patient interest and revenues. Hospitals may also have trouble getting medical malpractice insurance when their ratings slip. Insurance providers can also refuse to offer coverage for never events on the grounds that they are the responsibility of the treating facility.

Some doctors criticize the inclusions on this list, arguing that some may be extremely difficult to prevent. For example, death or serious disability due to a fall is a never event on most lists, but it is functionally impossible to prevent patient falls even with impeccable safety procedures.


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Post 3

@croydon - The idea of having something left inside a patient after surgery is just horrifying, but apparently it happens fairly often. You might think that it's just a hypothetical to say that one never event is operating on the wrong spot, but that has happened more than once as well.

Medical errors always seem so horrifying, but I guess we're all just human and they are bound to happen to someone, somewhere.

Post 2

@Fa5t3r - Honestly, I think falls should be put in whatever category is below this one. The never events list should be reserved for things that should never ever happen and falls are just too easy and too common. Not to mention that they aren't always easily defined as catastrophic, the way that something like giving a baby to the wrong family would be.

The other thing is that there are just too many factors contributing to the potential for falls for hospitals to completely prevent them. If a kid spills soda in the hallway, it's not like they can afford a sensor alerting the cleaners straight away. They would have to put impossible measures in place to prevent it.


if it is something like making sure no extraneous materials are sewn up in a patient (like sponges, for example) then there are very clear procedures that should always be followed and if they are there is no chance of this event happening.
Post 1

I can definitely see why a fall might be one of the events on this list, but I can also see why people might find it a bad choice, seeing as falls are so difficult to prevent.

I'd add a caveat that for a fall to be a never event it would have to be caused by negligence rather than by the patient or a visitor.

If a patient falls because they slip in water left standing in a hallway, that should count as a never event. If a patient falls because their friend helps them out of bed when they were advised to stay off their feet, that's hardly the hospital's fault.

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