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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 death in an American Society of Anesthesiologists 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 other than as intended
  • Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a health care facility

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 bed rails 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

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