AHRQ Patient Safety Network

The Collection > Never Events

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 (12)

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

•Medication Safety (9)

•Medical Complications (23)

•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 (32)

•Newspaper/Magazine Article (11)

•Press Release/Announcement (2)

•Tools/Toolkit (1)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (22)

•Active Errors (12)

•Latent Errors (4)

•Near Miss (3)

Approach to Improving Safety
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Never Events

Clinical Areas

•Medicine (45)

•Nursing (1)

•Pharmacy (2)

Target Audience

•Health Care Providers (33)

•Health Care Executives and Administrators (53)

•Non-Health Care Professionals (30)

•Patients (11)

Setting of Care

•Hospitals (50)

•Psychiatric Facilities (1)

•Residential Facilities (2)

•Ambulatory Care (3)

•Outpatient Surgery (4)

1 - 20 of 63

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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

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.

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.

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.

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.

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

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

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.

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.

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.

NEWSPAPER/MAGAZINE ARTICLE

Never events: Utah hospitals saw nearly 60 serious errors in 2007.

May H. Salt Lake Tribune. August 18, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Minnesota is first state with policy to stop billing after medical errors.

Lerner M. Star Tribune. September 18, 2007;News section:5B.

NEWSPAPER/MAGAZINE ARTICLE

Many Mass. hospitals will pay for errors.

Kowalczyk L. Boston Globe. September 17, 2007;Metro section:1A.

STUDY

The relationship between organizational leadership for safety and learning from patient safety events.

Ginsburg LR, Chuang YT, Berta WB, et al. Health Serv Res. 2010;45:607-632.

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.

NEWSPAPER/MAGAZINE ARTICLE

NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.

DerGurahian J. Mod Healthc. June 16, 2008;38:6.

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.

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.

BOOK/REPORT classic

The Economic Measurement of Medical Errors.

Shreve J, van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. Schaumburg, IL: The Society of Actuaries; 2010.

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