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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.
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.
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.
BOOK/REPORT
Adverse Health Events in Minnesota: Tenth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2014.
ORGANIZATIONAL POLICY/GUIDELINES
Preventing unintended retained foreign objects.
Sentinel Event Alert. October 17, 2013;(51):1-5.
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
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.
NEWSPAPER/MAGAZINE ARTICLE
Never events: Utah hospitals saw nearly 60 serious errors in 2007.
May H. Salt Lake Tribune. August 18, 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' land.
Carpenter D. Hosp Health Netw. November 2007;81:34-38.
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.
NEWSPAPER/MAGAZINE ARTICLE
No pay for "never event" errors becoming standard.
O'Reilly KB. American Medical News. January 7, 2008.
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.
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.
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