{1}
##LOC[OK]##
{1}
##LOC[OK]##
##LOC[Cancel]##
{1}
##LOC[OK]##
##LOC[Cancel]##
Skip Navigation
www.ahrq.gov
search
home
whatsnew
collection
primers
glossary
newsletter
mypsnet
newsletter
The Collection
>
Never Events
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
>
Narrow By
clear selections
Safety Target
•
Device-related Complications (2)
•
Diagnostic Errors (1)
•
Identification Errors (11)
•
Discontinuities, Gaps, and Hand-Off Problems (1)
•
Medication Safety (7)
•
Medical Complications (22)
•
Nonsurgical Procedural Complications (1)
•
Surgical Complications (28)
•
Transfusion Complications (4)
•
Psychological and Social Complications (3)
Origin/Sponsor
•
Australia and New Zealand (1)
•
Europe (3)
•
North America (56)
Resource Types
•
Audiovisual (1)
•
Book/Report (14)
•
Journal Article (28)
•
Legislation/Regulation (1)
•
Newspaper/Magazine Article (11)
•
Press Release/Announcement (2)
•
Special or Theme Issue (1)
•
Tools/Toolkit (1)
•
Web Resource (1)
Error Types
•
Epidemiology of Errors and Adverse Events (20)
•
Active Errors (12)
•
Latent Errors (4)
•
Near Miss (3)
Approach to Improving Safety
< All
Never Events
Clinical Areas
•
Medicine (42)
•
Nursing (1)
•
Pharmacy (2)
Target Audience
•
Health Care Providers (32)
•
Health Care Executives and Administrators (50)
•
Non-Health Care Professionals (32)
•
Patients (11)
Setting of Care
•
Hospitals (48)
•
Psychiatric Facilities (1)
•
Residential Facilities (2)
•
Ambulatory Care (3)
•
Outpatient Surgery (4)
1 - 20
of 60
Show Excerpt
Don't Show Excerpt
Sort by relevance
Sort by significance
Sort by title
Sort by date
Sort by author
dropdown
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.
COMMENTARY
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.
BOOK/REPORT
Adverse Health Events in Minnesota: Ninth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2013.
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.
STUDY
Patient characteristics and the occurrence of never events.
Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.
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.
NEWSPAPER/MAGAZINE ARTICLE
'Never' land.
Carpenter D. Hosp Health Netw. November 2007;81:34-38.
NEWSPAPER/MAGAZINE ARTICLE
More states shred bills for awful medical errors: patients in 23 states will no longer pay for certain mistakes, hospitals say.
Aleccia J. MSNBC News. August 12, 2008.
BOOK/REPORT
Never Events: Framework 2009/10.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
NEWSPAPER/MAGAZINE ARTICLE
No pay for "never event" errors becoming standard.
O'Reilly KB. American Medical News. January 7, 2008.
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.
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
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.
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.
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
A Comprehensive Guide to Managing Never Events and Hospital-Acquired Conditions.
Bunting RF Jr, Schukman J, Wong WB. Washington, DC: Atlantic Information Services, Inc.; 2009. ISBN: 1933801557.
1
2
3
4
Next >