AHRQ Patient Safety Network

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PATIENT SAFETY PRIMERS
Never Events

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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 (11)

•Discontinuities, Gaps, and Hand-Off Problems (1)

•Medication Safety (9)

•Medical Complications (24)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (29)

•Transfusion Complications (4)

•Psychological and Social Complications (4)

Origin/Sponsor

•Australia and New Zealand (1)

Resource Types

•Journal Article (30)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (11)

•Press Release/Announcement (2)

•Special or Theme Issue (1)

•Tools/Toolkit (1)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (22)

•Active Errors (11)

•Latent Errors (4)

•Near Miss (3)

Approach to Improving Safety
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Never Events

Clinical Areas

•Medicine (43)

•Nursing (1)

•Pharmacy (2)

Target Audience

•Health Care Providers (34)

•Health Care Executives and Administrators (52)

•Non-Health Care Professionals (31)

•Patients (12)

Setting of Care

•Hospitals (48)

•Psychiatric Facilities (1)

•Residential Facilities (2)

•Ambulatory Care (3)

•Outpatient Surgery (4)

1 - 20 of 63

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STUDY

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.

STUDY

Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1,946,831 operations in children.

Camp M, Chang DC, Zhang Y, Chrouser K, Colombani PM, Abdullah F. Arch Surg. 2010;145:1085-1090.

STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

COMMENTARY classic

Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.

Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.

STUDY

Surgical never events in the United States.

Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.

REVIEW

The recurring problem of retained swabs and instruments.

Mahran MA, Toeima E, Morris EP. Best Pract Res Clin Obstet Gynaecol. 2013 Apr 8; [Epub ahead of print].

STUDY

Retained surgical items: a problem yet to be solved.

Stawicki SP, Moffatt-Bruce SD, Ahmed HM, et al. J Am Coll Surg. 2013;216:15-22.

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

St. Paul, MN: Minnesota Department of Health; January 2013.

STUDY

Patient characteristics and the occurrence of never events.

Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.

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.

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.

REVIEW

Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.

Michaels RK, Makary MA, Dahab Y, et al. Ann Surg. 2007;245:526-532.

NEWSPAPER/MAGAZINE ARTICLE

A girl dies during restraint at hospital already criticized for problems.

Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1

STUDY

Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction.

Salisbury AC, Reid KJ, Alexander KP, et al. Arch Intern Med. 2011;171:1646-1653.

REVIEW

Interventions for reducing wrong-site surgery and invasive procedures.

Mahar P, Wasiak J, Batty L, Fowler S, Cleland H, Gruen RL. Cochrane Database Syst Rev. 2012;9:CD009404.

AUDIOVISUAL

Using the Targeted Solutions Tool for wrong site surgery: is your organization at risk?

Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; February 13, 2012.

BOOK/REPORT

The Power of Safety: State Reporting Provides Lessons in Reducing Harm, Improving Care.

Washington DC: National Quality Forum; 2010.

BOOK/REPORT

Never Events: Framework 2009/10.

National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.

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

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.

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