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The National Quality Forum’s Health Care “Never Events”

Surgical or Invasive Procedure events

  • Surgery or other invasive procedure performed on the wrong site
  • Surgery or other invasive procedure performed on the wrong patient
  • Wrong surgical or other invasive procedure performed on a patient
  • Unintended retention of a foreign object in a patient after surgery or other invasive procedure
  • Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient

Product or Device events 

  • Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting
  • Patient death or serious injury 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 injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting
    Applicable in: hospitals, outpatient/office-based surgery centers, long-term care/skilled nursing facilities

Environmental events

  • Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare setting
  • Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or are contaminated by toxic substances
  • Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a healthcare setting
  • Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting

Potential Criminal events

  • Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
  • Abduction of a patient/resident of any age
  • Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting
  • Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting

Patient Protection events

  • Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person
  • Patient death or serious injury associated with patient elopement (disappearance)
  • Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting

Radiologic events

  • Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area (new)
    Applicable in: hospitals, outpatient/office-based surgery centers, ambulatory practice settings/office-based practices

Care Management events 

  • Patient death or serious injury 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 injury associated with unsafe administration of blood products
  • Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting
  • Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy
  • Patient death or serious injury associated with a fall while being cared for in a healthcare setting
  • Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting
  • Artificial insemination with the wrong donor sperm or wrong egg
  • Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen
  • Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results