AHRQ Patient Safety Network

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PATIENT SAFETY PRIMERS
Never Events

Glossary >
Never Events : The list of never events has expanded over time to include adverse events that are unambiguous, serious, and usually preventable... Read Full Glossary Entry >

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Safety Target

•Device-related Complications (2)

•Diagnostic Errors (1)

•Identification Errors (12)

•Medication Safety (8)

•Medical Complications (22)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (27)

•Transfusion Complications (4)

•Psychological and Social Complications (4)

Origin/Sponsor

Resource Types

•Journal Article (29)

•Newspaper/Magazine Article (10)

•Press Release/Announcement (2)

•Tools/Toolkit (1)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (20)

•Active Errors (11)

•Latent Errors (3)

•Near Miss (2)

Approach to Improving Safety
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Never Events

Clinical Areas

•Medicine (43)

•Nursing (1)

•Pharmacy (2)

Target Audience

•Health Care Providers (33)

•Health Care Executives and Administrators (51)

•Non-Health Care Professionals (30)

•Patients (10)

Setting of Care

•Hospitals (47)

•Psychiatric Facilities (1)

•Residential Facilities (2)

•Ambulatory Care (3)

•Outpatient Surgery (4)

1 - 20 of 58

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STUDY

Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST).

Heddle NM, Fung M, Hervig T, et al; BEST Collaborative. Transfusion. 2012;52:1687-1695.

BOOK/REPORT classic

Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.

STUDY

Venous thromboembolism after trauma: a never event?

Thorson CM, Ryan ML, Van Haren RM, et al. Crit Care Med. 2012;40:2967-2973.

MULTI-USE WEBSITE

HAC Posting on Hospital Compare.

Centers for Medicare & Medicaid Services.

STUDY

Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.

Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010;25:1097-1101.

NEWSPAPER/MAGAZINE ARTICLE

'Never' land.

Carpenter D. Hosp Health Netw. November 2007;81:34-38.

BOOK/REPORT

2009 Utah Sentinel Events Data Report.

Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.

REVIEW

Inpatient fall prevention programs as a patient safety strategy: a systematic review.

Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Ann Intern Med. 2013;158(5 Pt 2):390-396.

BOOK/REPORT

Adverse Events in Hospitals: Overview of Key Issues.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.

BOOK/REPORT

To Err Is Human—But Don't Expect to Get Paid For It.

ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.

STUDY

The $17.1 billion problem: the annual cost of measurable medical errors.

Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. Health Aff (Millwood). 2011;30:596-603.

REVIEW

Inpatient suicide: preventing a common sentinel event.

Tishler CL, Reiss NS. Gen Hosp Psychiatry. 2009;31:103-109.

FACT SHEET/FAQS

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

COMMENTARY classic

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.

BOOK/REPORT classic

Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2012. Report No. OEI-06-09-00091.

STUDY

To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective.

Fareed N, Mick SS. Health Care Manage Rev. 2011;36:288-298.

STUDY

Medicare's policy not to pay for treating hospital-acquired conditions: the impact.

McNair PD, Luft HS, Bindman AB. Health Aff (Millwood). 2009;28:1485-1493.

COMMENTARY

CMS's hospital-acquired condition lists link hospital payment, patient safety.

Clancy CM. Am J Med Qual. 2009;24:166-168.

BOOK/REPORT

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220.

REVIEW

Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review.

Sullivan N, Schoelles KM. Ann Intern Med. 2013;158(5 Pt 2):410-416.

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