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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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STUDY
Surgical never events in the United States.
Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.
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.
ORGANIZATIONAL POLICY/GUIDELINES
Preventing unintended retained foreign objects.
Sentinel Event Alert. October 17, 2013;(51):1-5.
BOOK/REPORT
Adverse Health Events in Minnesota: Tenth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2014.
REVIEW
Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.
Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.
COMMENTARYclassic
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
Patient characteristics and the occurrence of never events.
Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.
BOOK/REPORTclassic
Serious Reportable Events in Healthcare—2011 Update.
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
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.
STUDYclassic
Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
NEWSPAPER/MAGAZINE ARTICLE
'Never' land.
Carpenter D. Hosp Health Netw. November 2007;81:34-38.
NEWSPAPER/MAGAZINE ARTICLE
No pay for "never event" errors becoming standard.
O'Reilly KB. American Medical News. January 7, 2008.
BOOK/REPORT
Never Events: Framework 2009/10.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
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.
NEWSPAPER/MAGAZINE ARTICLE
Never events: Utah hospitals saw nearly 60 serious errors in 2007.
May H. Salt Lake Tribune. August 18, 2008.
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.
STUDYclassic
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.
PRESS RELEASE/ANNOUNCEMENT
Patient safety: healthcare acquired conditions and serious reportable events.
Washington, DC: National Quality Forum; September 2009.
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