eMedinewS Editorial

Health Care 2,544 Comments

Never events

Dear Colleague

Implications: Why know them

  1. Mediclaim may not pay.
  2. PSU may not reimburse.
  3. CGHS may not pay.
  4. CPA may order compensation.
  5. Patient may not pay.
  6. MCI or state councils may be asked to classify them under “never events”.

‘Never events’ or events that should never occur are 28 occurrences on a list of inexcusable outcomes in a health care setting. The list was compiled by the US National Quality Forum (NQF). They are defined as adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability. The term ‘Never Event’ was first introduce by Ken Kizer, MD, former CEO of NQF in 2001. Several US states have enacted laws requiring the disclosure of never events at hospitals and various remunerative or punitive measures for such events.

A recent Leapfrog Group Study finds that roughly half of the 1,285 hospitals that responded to their survey waive fees for never events, and that hospitals that do waive fees are much more likely to have perfect scores on the Leapfrog Safe Practices Score survey.

The 28 never events are:

  1. Artificial insemination with the wrong donor sperm or donor egg.
  2. Unintended retention of a foreign object in a patient after surgery or other procedure
  3. Patient death or serious disability associated with patient elopement (disappearance)
  4. 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)
  5. Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA–incompatible blood or blood products
  6. Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility
  7. Patient death or serious disability associated with a fall while being cared for in a healthcare facility
  8. Surgery performed on the wrong body part
  9. Surgery performed on the wrong patient
  10. Wrong surgical procedure performed on a patient
  11. Intraoperative or immediately post–operative death in an ASA Class I patient
  12. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
  13. 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
  14. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
  15. Infant discharged to the wrong person
  16. Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
  17. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility
  18. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
  19. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
  20. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
  21. Patient death or serious disability due to spinal manipulative therapy
  22. 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
  23. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
  24. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
  25. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
  26. Abduction of a patient of any age
  27. Sexual assault on a patient within or on the grounds of the healthcare facility
  28. 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, and

4. Waive costs directly related to the event.

Medscape adds to the list

1. Catheter–associated urinary tract infection

2. Deep–vein thrombosis/pulmonary embolism related to hip and knee replacements

3. Surgical site infections

4. Manifestations of poor glycemic control, including hypoglycemic coma

NHS list (adds)

As specified in The operating framework for the NHS in England 2010/11, from April 2010, primary care trusts will be expected to seek recovery of the cost of the procedure/treatment where one of the following seven Never Events occurs:

  • Wrong route administration of chemotherapy
  • Misplaced naso or orogastric tube not detected prior to use
  • Inpatient suicide using non–collapsible rails
  • In–hospital maternal death from post–partum haemorrhage after elective caesarean section
  • Intravenous administration of mis–selected concentrated potassium chloride

Hospital–acquired infections such as MRSA or C.diff are not included on this list.

IVF: Artificial insemination with the wrong donor sperm or donor egg.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor